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FRACTURES 


FRACTURES 


TREATMENT 
OF  FRACTURES 


FRACTURES  OF 
THE  LOWER  JAW 


FRACTURES  OF 
THE  ORBIT 


BY 


AUTHORS 

R.  LERICHE 
L.  IMBERT 
PIERRE  REAL 
FELIX  LAGRANGE 
CH.   FEVRJER 


EDITORS    AND    XRAKSLATORS 

F.  F.  BURGHARD 

J.  F.  COLYER 

HERBERT  CHILD 

J.  HERBERT  PARSONS 


With  Three   Huxdred  Thirty-eight  Illustrations 
AND  Eleven  Plates 


D.    APPLETON    AND    COMPANY 

NEW    YORK     AND    LONDON 

1918 


Copyright,  1918,  by 
D.  Appleton  and  CompaDy 


Printed  in  the  United  States  of  America 


CONTENTS 

SECTION  I 

TREATMENT  OF  FRACTURES 

BY 

R.  Leriche 

PAGE 

Chapter  I.  General  Considerations  Upon 
Wounds  of  Joints,  Their 
Gravity  and  Their  Treat- 
ment         1 

Gravity  of  Wounds  of  Joints ...       1 
General  Treatment  of  Wounds  of 
the  Synovial  Membrane  and  of 
Compound       Fractures       into 

Joints 8 

General  Technique  of  Operations 

upon  the  Joints 18 

r  {Continued)  General     Survey     of     Present 
Methods       for       Obtaining 
Wound  Asepsis  .    ......    34 

The  Carrel-Dakin  Method    ...     37 
Dakin    Solution    Without    Boric 

Acid    . •    •        •     40 

Dakin  Solution  With  Boric  Acid    .     41 
Titration  of  the  Solution  (Lyle)    .     42 

Equipment 42 

Employment  of  Hypochlorite  So- 

\  lutions 45 

Dichloramin-T  in  Oil  Method    .    .     5^ 
vii 


viii  CONTENTS 

PAGE 

"Javelle   Water"   in   the   Treat- 
ment of  War  Wounds 65 

Hypochlorous  Acid  Preparations — 

Eusol  and  Eupad 67 

Hypertonic  Solutions  (Lymphago- 

gic  Agents) 71 

Salt    Pack    Method    of    Wound 

Treatment 72 

Magnesium  Chloride    ......     74 

Sugar  Treatment  of  Wounds ...     75 

Collargol 76 

Bipp  (Rutherford  Morison's  Meth- 
od) ..    . 77 

lodated  Starch . 80 

Flavine  (Acri-  and  Pro-flavine) .    .     80 
Brilliant  Green,  Paste  and  Lotion     83 

Methyl  Violet 86 

Magnesium  Sulphate 86 

Vincent's  Powder 88 

Sunlight  and  Ozone  Treatment  of 
Infected  Wounds .......     90 

Acetozone .     93 

Delbet's  Pyoculture 94 

Vaccine  and  Serum  Treatment  of 
Infected  Wounds .    ......     95 

Donaldson's    Method    (Introduc- 
tion of  Living  Anaerobes)   ..    .    .100 

Chapter       IL  Wounds   and   Fractures   of   the 

Shoulder 102 

Anatomical    Types    and'  Clinical 

Course 102 

Primary  Therapeutic  Indications.   105 

Operative  Technique 112 

Post-Operative  Treatment .    .    .    .117 


CONTENTS  ix 

PAGE 

Evacuation  of  Patients  with  Shoul- 
der Wounds 124 

Treatment  of  Patients  Seen  Late 
or  After  Evacuation     .    .    .    .    .125 

Chapter     III.  Wounds  and   Fractures   of   the 

Elbow 129 

Anatomical    Types    and    Clinical 

Course 129 

Primary  Therapeutic  Indications.    134 

Operative  Technique 149 

After-Treatment 154 

Evacuation  of  Patients  with  El- 
bow Wounds 160 

Treatment  of  Patients  Seen  Late 
or  After  Evacuation 162 

Chapter     IV.  Wounds   and   Fractures   of   the 

Wrist 170 

Anatomical    Types    and    Clinical 

Course 170 

Primary  Therapeutic  Indications.    171 

Operative  Technique 175 

Post-Operative  Treatment ....  177 
Evacuation  of  Patients  with  Wrist 

Wounds 180 

Treatment  of  Patients  Seen  Late 

or  After  Evacuation 180 

Chapter       V.  Wounds   and   Fractures   of   the 

Hip 184 

Anatomical    Types    and    Clinical 

Course 184 

Primary  Therapeutic  Indications.    187 
Operative  Technique 190 


X  CONTENTS 

PAGE 

Post-Operative  Treatment .  .  .  .  193 
Evacuation  of  Patients  with  Hip 

Wounds 197 

Treatment  of  Patients  Seen  Late 

or  After  Evacuation 197 

Chapter      VI.  Wounds   and    Fractures   of   the 

Knee 201 

Anatomical    Types    and    Clinical 

Course 201 

Primary  Therapeutic  Indications,    206 
Operative  Technique    ......  216 

Post-Operative  Treatment .     .    .    .  218 

Evacuation  of  Patients  with  Knee 

Wounds 225 

Treatment  of  Patients  Seen  Late 

or  After  Evacuation 225 

Chapter    VII.  W^ounds   and   Fractures   of   the 

Ankle 234 

Anatomical   Types    and    Clinical 

Course 234 

Primary  Therapeutic  Indications.   238 

Operative  Technique 245 

Post-Operative  Treatment ....  248 
Evacuation  of  Patients  with  Ankle 

Wounds 25£ 

Treatment  of  Patients  Seen  Late 

or  After  Evacuation 25^ 

Chapter  VIIL  W^ounds  and  Fractures  of  the 
Anterior  Tarsus  and  the 
Fore-Part  of  the  Foot    .    .    .  255 

Anatomical  Types  and  Clinical 
Course ^55 

Primary  Therapeutic  Indications.   256 


CONTENTS  xi 

PAGE 

Operative  Technique    .......  262 

Post-Operative  Treatment ....  266 

Evacuation  of  Patients  with.  An- 
terior Tarsal  Wounds 268 

Treatment  of  Patients  Seen  Late 
or  After  Evacuation    ......  268 

Chapter     IX.  Multiple  Joint  Wounos 272 

Chapter  X.  A  General  Study  of  Shaft  Frac- 
tures.   . 277 

Pathological  iVnatomy  of  the  Seat 
of  a  Fracture  in  Its  Earliest 
Stage  .     . 280 

Immediate  Results  of  Fracture, 
and  the  Normal  Course  to  Re- 
covery        ....  292 

Pathological  Changes  in  a  Frac- 
ture,  294 

Chapter  XI.  General  Principles  in  the  Con- 
servativeTreatment  of  Frac- 
tures  313 

Operative    Disinfection    of    Open 

Fractures  . 314 

Initial  Operative  Disinfection  of 
Fractures  in  the  First  Few 
Hours :  Exploratory  and  Pro- 
phylactic Esquillectomy .  .  .315 
Secondary  Operative  Disinfec- 
tion ^of  Clinically  Infected 
Fractures :  Esquillectomy  and 
Drainage :  Total  Subperios- 
teal Esquillectomy    328 

General     Indications     for     the 
Operation 331 


xii  CONTENTS 

PAGE 

Technique  of  Sub-periosteal  Es- 
quillectomy 343 

The  Reduction  of  Gunshot  Frac- 
tures   353 

The  Immobihsation  of  Fractures    .  362 

Chapter   XII.  Fractures  of  the  Humerus  .    .    .  385 
Fracture  of  the  Neck  of  the  Hu- 
merus (Sub-epiphyseal  Fracture)  385 

Sub-deltoid  Fracture 400 

Fracture    of    the    Middle    of    the 

Shaft 406 

Supra-condylar  Fracture  of  the 
Elbow. 433 

Chapter  XIII.  Fractures  of  the  Forearm  .    .    .  439 
Fractures  of  Both  Bones  of  the 

Forearm 441 

Fractures  Just  Below  the  Elbow 

Joint 441 

Fractures  of  the  Shafts  ....  446 
Fractures  Just  Above  the  Wrist .  460 
Fractures  of  the  Radius  Alone  .  .  465 
Fracture  of  the  Shaft  .....  465 
Fracture  of  the  Lower  Radial 

Epiphysis  . 476 

Fractures  of  the  Ulna 484 

Chapter  XIV.  Multiple  Fractures  of  the  Upper 

Limb 490 

CHAi'TER    XV.  Fractures  of  the  Femur  ....  494 
Sub-Trochanteric  Fracture.    .    .    .  494 
Fractures  of  the  Shaft;    the  So- 
called  Fractures  of  the  Thigh    .  507 
Supra-Condylar  Fractures  ....  547 


CONTENTS  xiii 

PAGE 

Chapter  XVI.  Fractures  of  the  Leg 554 

Fracture  of  Both  Bones  of  the  Leg .   554i 

Fracture  of  the  Tibia 574 

Fracture  of  the  Fibula 577 

ChapterXVII.  Multiple  Fractures  of  the  Low- 
er Limb 581 

SECTION  II 
FRACTURE  OF  THE  LOWER  JAW 

BY 

L.  Imbert  and  p.  Real 

Chapter        I.  Introduction 585 

Chapter       II.  Etiology  .    . 597 

Chapter     III.  Pathological  Anatomy 599 

Incomplete  Fracture 600 

Complete  Fracture 602 

Large   Loss   of   Bony   Substance. 

Shattering 622 

Large  Loss   of  Substance   of  the 

Soft  Parts 623 

Anatomical  Development  ....  623 

Chapter      IV.  Symptoms  and  Diagnosis     ....  629 

Recent  Fracture    ........  633 

OldFracture 640 

Fracture  of  the  Angle 641 

Fracture  of  the  Ramus    .....  642 
The  Use  of  Radiography  in  Man- 

dubular  Fracture .  642 

Closure  of  the  Jaws 645 

Clinical  Development 649 

Chapter       V.  Mechanical  Treatment  .....  659 
Elementary  Principles 659 


xiv  CONTENTS 

PAGE 

The  Immediate  Treatment  of  Le- 
sions    662 

Mechanical  Treatment  of  Frac- 
tures      .    .  666 

Treatment  of  Pseudo-Arthrosis .     .  710 
Treatment  of  Malocclusion    .    .    .  727 
Mechanico-Therapeutic        Treat- 
ment of  Myotonic  Construction 
of  the  Maxillae.    .    .    .    .    .    .    .730 

Chapter      VI.  Surgical  Treatment 734 

Osteo-Synthesis 735 

Operative  Technique 736 

Results  of  Osteo-Synthesis .    .    .  748 
Bony    and    Cartilaginous    Grafts. 
Actual  Results  .    .......  751 

Chapter    VII.  Assessment  of  the  Disablements 
Consequent   Upon   Fracture 

OF  THE  Mandible 763 

Loss  of  Teeth,  Complicated  by 
Fracture  of  the  Alveolar  Border 
but  Without  Complete  Fracture  765 

Fractures 767 

Closure  of  the  Jaws .    ......  771 

SECTION  III 
FRACTURES  OF  THE  ORBIT 

BY 

Felix  Lagrange 

Chapter        I.  Historical 777 

Chapter       II.  The  Orbital  Cavity 788 

Conformation 788 


CONTENTS  XV 

PA.GE 

Resistance  to  Injury 794 

Vulnerability  of  the  Orbit    ....  798 

Chapter     III.  General  Considerations  upon  the 
Atiology    of    Fractures    of 

the  Orbit 802 

Fractures  of  the  Orbit 802 

Pathogenesis 807 

Chapter      IV.  Fractures    oy    the    Orbit    with 

Preservation  of  the  Eyeball.  813 
The  Laws   Governing  the  Affec- 
tions of  the  Visual  Apparatus  in 
Injuries  of  the  Orbit  with  Pres- 
ervation of  the  Orbit    .....  813 
Pathology  of  the  Visual  Disorders  849 
Description  of  the  Visual  Defects .   853 
Symptoms  and  Diagnosis    ....  934 

Chapter       V.  Fractures  of  the  Orbit  with  De- 
struction OF  the  Eyeball    .    .  938 
Fractures  Implicating  the  Neigh- 
bouring Cavities    946 

Chapter      VI.  Treatment  of  Fractures  of  the 

Orbit  and  Their  Complications  970 
Superior  Orbital  Margin  and  Wall  971 
Fractures  of  the  Internal  Margin 
and  Wall    ..........  973 

Fractures  of  the  Inferior  Margin 

and  Wall .  973 

Fractures  of  the  External  JNIargin 
and  Wall 974 

Chapter    VII.  Treatment  of  Ocular  Complica- 
tions   983 

Sympathetic  Ophthalmia    .    .    .    .983 


xvi  CONTENTS 

PAGE 

Traumatic  Cataract 988 

Retinal  Detachment 990 

Chapter  VIII.  Reparative  Surgery  of  Orbital 

Fractures 993 

Restoration  of  the  Eyehds ....  993 
Restoration   of   the   Conjunctival 

Culs-de-sac 994 

Repair  of  Damage  to  the  Orbital 
Walls  and  in  the  Bone    .    .    .    .997 

Conclusions 1015 

List  of  Case  Reports 1019 

Index 1021 


SECTION  I 

TREATMENT  OF 
FRACTURES 


THE 

TREATMENT  OF  FRACTURES 

PAET  I 

FRACTURES  INVOLVING  JOINTS 

CHAPTER    I 

GENERAL  CONSIDERATIONS  UPON  WOUNDS  OF 
JOINTS,  THEIR  GRAVITY  AND  THEIR  TREAT- 
MENT 

I.  Gravity  of  Wounds  of  Joints 

Wounds  of  the  joints,  which  in  civil  practice  have 
always  had  the  reputation  of  being  very  serious,  are 
among  the  most  formidable  injuries  which  the  surgeon 
at  the  front  is  called  upon  to  treat.  It  may  be  added 
with  truth  that  they  are  perhaps  those  for  which  most 
can  be  done  if  he  intervenes  in  time. 

Their  gravity  is  due  to  three  causes. 

(a)  The  projectile  which  strikes  the  patient  carries 
with  it  some  particles  of  clothing  which  it  deposits  in 
the  joint  whether  it  remains  there  itself  or  whether  it 
passes  out  again.  These  particles  carry  various  germs 
which  there  find  conditions  perfectly  suited  to  their 
rapid  development,  since  they  are  shut  up  in  a  closed 
cavity  sheltered  from  everything  which  might  hinder 
their  growth. 


2        THE   TREATMENT  OF  FRACTURES 

(6)  The  damaged  synovial  membrane,  which  is  highly 
absorbent,  has  numerous  folds  and  recesses  in  which 
the  virulence  of  the  microbes  increases  the  more  rapidly 
because  the  recesses  are  shut  off  from  the  exterior,  and 
hence  the  microbes  are  not  amenable  to  exposure  to 
the  air,  which  is  essential  in  the  treatment  of  all 
septic  wounds. 

(c)  The  synovial  injury  is  almost  always  compHcated 
by  a  fracture  of  the  articular  surface.  Doubtless  pure 
synovial  injuries  are  to  be  found,  either  with  or  without 
the  presence  of  the  missile.  In  the  knee  such  a  con- 
dition is  not  rare,  but  everywhere  else,  even  in  the 
shoulder,  it  is  quite  exceptional  ;  practically,  a  joint 
injury  is  almost  synonymous  with  a  fracture  of  the 
joint.  Even  in  the  knee  bony  injury  is  always  to  be 
expected  and  considerably  aggravates  the  prognosis ; 
arthritis  is  then  conjoined  with  osteomyelitis,  for  the 
fissures  extending  up  into  the  shaft  carry  the  infection 
for  a  long  distance,  and  if  the  patient  escapes  severe 
early  infection  he  is  very  likely  to  die  of  chronic  septi- 
caemia. 

Only  one  type  of  joint  wounds  remains  almost 
always  uncomplicated  by  these  formidable  conditions  : 
the  bullet  wounds  with  punctiform  openings  run  a 
course  similar  to  that  of  injuries  not  exposed  to  the 
air.  A  long-range  bullet  of  high  velocity  only  makes 
an  almost  imperceptible  skin  wound,  meets  the  body 
point  foremost,  passing  through  the  clothing  without 
taking  anything  with  it,  and  perforates  the  tissues 
without  producing  the  great  explosive  damage  which 
bullets  fired  at  short  range  so  often  do.  The  wounds 
thus  made  generally  remain  aseptic. 

In  all  other  cases  there  is  nearly  always  grave  joint 
sepsis  which  develops  in  one  o^  the  following  three 
principal  types  : 

First  Type  of  Joint  Infection. — ^The  sepsis 
spreads  with  frightful  rapidity.  In  a  few  hours  the 
temperature  reaches  40°  C.  (104°  F.),  the  general  con- 


GENERAL   CONSIDERATIONS  3 

dition  is  bad  ;  the  patient  appears  profoundly  toxic. 
The  joint  is  distended  and  very  painful,  and  the  whole 
limb  is  oedematous.  Death  ensues  in  three  or  four 
days  from  septicaemia,  with  or  without  gangrene  ; 
secondary  amputation  or  disarticulation  rarely  saves 
one-third,  certainly  not  one-half  of  the  patients. 

Second  Type  of  Joint  Infection. — ^One  sees  here 
the  development  of  septic  local  phenomena  of  increas- 
ing gravity.  The  limb  presents  marked  oedematous 
swelhng,  the  joint  is  swollen,  hot,  and  very  painful ; 
the  least  movement  makes  the  patient  cry  out,  and 
there  are  foul  sloughs  on  the  wound  and  a  sero-purulent 
discharge  oozes  from  the  wound  of  entry,  about  which 
there  is  often  localised  gas  crepitation.  The  tempera- 
ture oscillates  markedly  and  the  general  condition  is 
profoundly  depressed.  One  operation  after  another 
may  be  performed,  each  too  late.  If  the  knee,  the  hip, 
or  even  the  shoulder  be  the  joint  concerned,  the 
mortality  is  high  in  spite  of  amputation  ;  the  case 
runs  its  course  in  from  eight  to  ten  days. 

Third  Type  of  Joint  Infection. — ^Here  the  in- 
juries are  limited.  There  is  copious  suppuration  with 
purulent  tracks  communicating  with  the  joint ;  if 
nothing  be  done,  a  chronic  septicaemia  supervenes.  In 
the  case  of  the  shoulder,  the  elbow,  and  the  ankle, 
repeated  incisions  and  the  removal  of  bony  fragments 
generally  succeed  in  keeping  the  complications  under 
and  the  patient  slowly  gets  well  with  an  ankylosed 
joint.  In  the  case  of  the  knee  and  the  hip,  amputation 
and  death  are  frequent.  Patients  who  have  appar- 
ently recovered  are  liable  to  numerous  risks,  such  as 
recurrent  articular  osteitis,  bone  abscesses,  and  per- 
sistent sinuses. 

This  last  cUnical  type  is  the  one  seen  almost  exclu- 
sively at  the  base ;  it  and  the  bullet  wounds  with 
small  openings  comprise  the  forms  of  joint  wounds  most 
frequently  seen  by  many,  and  that  is  why  some  sur- 
geons at  the  base  hospitals  have  got  it  into  their  heads 


4   THE  TREATMENT  OF  FRACTURES 

that  wounds  of  joints  are  not  grave.  No  view  could  be 
falser  or  more  dangerous,  for  it  leads  to  the  advocacy 
of  treatment  at  the  front  which  is  inadequate  for  the 
severely  wounded,  and  to  the  proscription  of  the  really 
conservative  methods  as  being  too  severe. 

It  can  never  be  too  often  repeated  that  it  is  a  long 
way  from  the  aid-post  to  the  base  hospital ;  those  who 
arrive  at  the  latter  with  an  articular  fracture  are  only 
those  who  have  been  able  to  bear  the  journey  ;  the 
worst  cases  have  been  left  behind  at  various  stages 
along  the  route.  To  take  account  only  of  those  who 
arrive  at  the  base  is  to  omit  two-thirds  of  them  at 
least. 

This  is  directly  proved  by  statistics. 

In  examining  the  figures  of  the  wounded  who  were 
evacuated  from  the  aid-posts  of  one  division  during  the 
winter  of  1914,  I  made  a  point  of  noting  the  different 
degrees  of  gravity  of  the  wounds  which  I  saw,  and  here 
are  the  results.  Of  614  wounds  of  the  upper  Umbs, 
457  were  considered  fit  for  immediate  evacuation  ; 
.157  called  for  immediate  intervention. 

Of  601  wounds  of  the  lower  limbs,  451  were  appar- 
ently shght,  and  150  required  operation  on  the  spot. 

Thus,  out  of  1,215  wounds  of  hmbs,  908  were 
evacuated  from  the  front  and  307,  or  a  quarter, 
did  not  leave  the  ambulances  in  the  immediate  battle 
area. 

The  908  who  were  considered  fit  to  be  evacuated 
during  the  first  few  hours  after  being  wounded  only 
quitted  the  anny  zone  the  ev.ening  of  the  next  day, 
after  a  whole  day's  journey  and  after  having  passed 
through  three  successive  surgical  lines,  where  a  great 
number  of  them  were  retained  because  their  wounds 
had  become  aggravated  or  their  pain  had  become 
worse.  Those  who  reached  a  base  hospital  after  a 
two  or  three  days'  journey  were  only  slight  cases  in 
comparison  with  those  who  had  been  left  behind  en 
route. 


GENERAL   CONSIDERATIONS  5 

Among  the  307  wounded  who  required  immediate 
surgical  intervention,  there  were  obvious  joint  injuries 
in  more  than  a  third.  It  will  thus  be  seen  what  reliance 
is  to  be  placed  upon  the  opinion  of  those  at  the  base 
who  think  that  they  receive  wounded  straight  from  the 
front. 

Here  are  a  few  more  figures  : 

At  the  beginning  of  November  my  ambulance  re- 
ceived in  thirty  hours  489  wounded  comprising  251 
injured  limbs,  of  which  178  were  caused  by  bullets 
and  only  83  by  shell-spUnters. 

Of  138  wounds  of  the  upper  limbs,  36  were  detained 
(29  bullet  wounds,  7, by  shell-sphnters),  and  102  were 
considered  fit  for  "evacuation  from  the  zone  of  the 
divisional  ambulances  (74  bullet  wounds,  28  by  shell- 
sphnters). 

Of  123  wounded  in  the  lower  hmbs,  79  were  evacu- 
ated (58  bullet  wounds,  21  by  shell-sphnters)  and  44 — 
more  than  one-third — ^were  detained  (27  bullet  wounds, 
17  by  shell-splinters).  Half  of  the  wounded  detained 
had  evident  joint  injuries. 

On  the  night  of  December  24-25  we  received 
150  w^ounded.  Aniong  43  having  injuries  of  the 
upper  limbs,  15 — i.e.  28  % — presented  fractures  of 
the  shaft  or  articular  ends,  and  were  treated  on  the  spot. 
Among  27  having  injuries  of  the  lower  limbs,  13 — or 
almost  50  % — presented  fractures  of  the  shaft  or  articu- 
lar ends,  and  were  not  evacuated.  These  few  figures 
enable  one  to  understand  how  greatly  mistaken  is  the 
calculation  of  those  who  judge  the  real  gravity  of  joint 
fractures  by  what  they  see  at  the  base. 

In  dealing  with  war-surgery  it  is  always  necessary 
to  be  precise  as  to  where  the  operation  is  performed 
when  one  talks  of  the  nature  of  the  surgical  procedure, 
for  there  is  a  fundamental  difference  in  the  gravity 
of  the  wounds  seen  at  a  station  situated  half  an  hour's 
journey  from  the  line  of  fire  and  those  seen  twenty-five 
miles  behind  ;  and  much  more  betv^een  those  received 


6        THE   TREATMENT  OF  FRACTURES 

by  the  divisional  ambulance  and  those  which  arrive 
at  a  base  hospital  after  two  or  three  days  of  successive 
transfers.  Since  the  conditions  are  not  similar,  treat- 
ment that  would  appear  conservative  at  the  base  is 
not  so  at  the  front  because  it  would  be  insufficient, 
while  an  operation  that  would  be  thought  conservative 
at  the  front  might  appear  too  radical  at  the  base. 

It  is  owing  to  their  inability  to  draw  this  necessary 
distinction  that  some  surgeons  have  proclaimed  the 
failure  of  conservative  surgery,  while  others,  with  a 
like  conviction,  have  been  able  to  recommend  syste- 
matic abstention  from  operation  and  advise  immobili- 
sation pure  and  simple,  as  was  advocated  in  military 
surgery  before  the  present  war. 

For  the  surgeon  at  the  front  who  has  to  sort  out 
his  patients  without  delay,  articular  fractures  fall 
into  three  large  groups  : 

1.  Crushing  of  a  Limb  in  the  neighbourhood  of  a 
Joint. — Here  there  is  a  smashing-up  of  the  bones  and 
joint  accompanied  by  extensive  destruction  of  muscles 
and  irreparable  vasculo-nervous  injuries,  for  which 
amputation  or  disarticulation  is  alone  of  any  use. 
The  best  time  to  perform  the  operation  is  the  only 
matter  open  to  discussion  in  these  cases. 

The  injured  arrive  in  a  condition  of  extreme  shock. 
None  of  them  are  evacuated  from  the  front  line ; 
unless  there  is  an  enormous  number  of  cases,  none  are 
passed  through  to  the  2nd  Ambulance  station,  much 
less  the  clearing-station  ;  they  do  not  get  past  the 
first  surgical  line  {relai).  Whatever  be  the  treatment, 
whether  by  immediate  or  delayed  amputation,  the 
mortality  is  considerable.  This  might  perhaps  be 
diminished  by  performing  transfusion  of  blood  before 
operation,  if  this  were  possible,  and  it  might  well  be 
tried. 

But  to  conditions  such  as  these  the  name  of  joint- 
wounds  is  inapplicable,  and  to  include  them  in  the 
same  category  as  those  in  which  the  joint  injuries  are 


GENERAL   CONSIDERATIONS  7 

more  or  less  uncomplicated  is  to   create  confusion. 
It  will  not  be  done  here. 

%  Comminuted  Articular  Fractures  with  or 
without  fissures  radiating  into  the  shaft,  but 
with  the  main  vessels  and  nerves  intact. — tms  is 
the  group  comprising  wounds  of  medium  severity  which 
form  the  great  majority  of  joint  fractures.  There  are 
all  degrees  between  the  complete  destruction  of  a 
joint  on  the  one  hand  and  the  simple  parietal  fracture 
of  an  articular  end  on  the  other.  The  treatment  of 
these  will  be  discussed  almost  exclusively  in  this  book. 
In  the  case  of  each  articulation  I  shall  consider  the 
treatment  of  a  joint  wound  without  fracture,  with  or 
without  the  missile  present. 

3.  Bullet  Wounds  of  Joints  with  a  Punctiform 
Skin  Wound,  with  or  without  fracture. — ^These 
behave  like  simple  fractures  and  are  quite  mild  in 
character,  provided  that  rigorous  immobihsation  is 
secured.  They  are  really  punctured  wounds  of  the 
synovial  membrane,  simple  trochar-like  wounds  of 
the  bone  with  or  without  radiating  fissures  of  the  shaft, 
and  they  result  from  long-range  bullet-wounds. 

In  the  case  of  the  knee,  a  copious  hsemarthrosis  often 
requires  one  or  more  aspirations  which  it  is  well  to 
make  quite  early.  Otherwise  prolonged  immobihsa- 
tion alone  suffices  for  cure,  but  it  must  be  kept  up  for 
a  long  time  and  movement  must  only  be  commenced 
when  all  pain  has  completely  disappeared. 

I  have  had  12  cases  of  this  kind — 7  of  the  knee, 
3  of  the  shoulder,  and  2  of  the  elbow  ;  they  wore  a 
plaster  casing  for  from  three  weeks  to  two  months.  They 
all  recovered,  with  very  satisfactory  recovery  of  the 
functions  of  the  joint. 

Briefly,  these  cases  are  of  the  mild  type  which  before 
the  war  was  considered  the  usual  type  of  bullet  wounds 
of  joints.  Their  mildness  is  explained  by  the  con- 
ditions under  which  the  wound  is  made ;  the  bullet 
enters  with  its  pointed  end  foremost,  passes  through 


8   THE   TREATMENT  OF  FRACTURES 

the  clothing  between  its  threads  without  carrying  any 
with  it.  It  traverses  the  skin,  the  muscles,  and  the 
synovial  membrane  without  depositing  in  them  any 
infected  fragments  of  clothing,  and  the  fracture, 
whatever  be  its  type,  whether  erosion,  cartilaginous 
abrasion,  furrow,  gutter,  or  bony  perforation,  is  an 
aseptic  fracture,  and  runs  its  course  as  such  without 
infection. 

But  no  rule  is  absolute,  and  one  can  quite  well 
understand  that  infection  may  occur  in  these  joint 
wounds  with  tiny  skin  orifices.  So  these  patients  ought 
always  to  be  very  carefully  supervised  ;  their  tempera- 
tures should  be  taken  regularly,  the  joint  should  be 
examined  daily  without  necessarily  removing  the 
plaster  each  time.  If  after  the  first  few  days  the 
primary  fever  caused  by  the  haemarthrosis  persists, 
if  the  temperature,  after  having  fallen  to  normal, 
suddenly  goes  up,  if  the  general  condition  is  affected, 
or  if  theje  is  the  least  suspicion  of  infection,  free' 
arthrotomy  may  become  necessary.  I  have  never 
had  occasion  to  perform  it  under  these  circum- 
stances. 

All  the  foregoing  remarks  about  joint  injuries  with 
punctiform  skin  wounds  refer  to  the  injuries  made  by 
bullets.  In  the  case  of  quite  a  minute  wound  caused 
by  a  small  spUnter  of  a  shell  or  grenade,  infective  com- 
pHcations  are  to  be  feared.  The  wounds  made  under 
these  circumstances  resemble  those  in  the  second 
category  above  and  will  be  considered  with  them. 

II.  General  Treatment  of  Wounds  of  the  Synovial  Membrane 
and  of  Compound  Fractures  into  Joints 

Since  the  crushing  of  limbs  in  the  neighbourhood  of 
joints  requires  amputation,  and  bullet  wounds  ©f 
joints  with  very  small  skin  wounds  are  amenable  to 
simple  immobilisation,  there  is  only  a  single  category 
of  joint  wounds  in  which  the  treatment  is  varied  and 


GENERAL   CONSIDERATIONS  9 

open  to  discussion.  It  forms  our  second  group  and 
is  a  very  large  one. 

Before  seeing  what  it  is  best  to  do  for  one  of  these 
cases  it  is  well  to  define  the  principal  types  which 
can  be  identified  by  radiography. 

They  are,  in  order  of  increasing  anatomical  gravity  : 

[a)  A  wound  of  the  synovial  membrane,  without  a 
bony  lesion  but  with  the  projectile  free  inside  the 
joint  ;  this  is  rarely  seen  except  in  the  knee,  and  is 
very  exceptional  elsewhere  {e.g.  the  shoulder). 

(6)  A  wound  of  the  synovial  membrane  with  the 
projectile  embedded  in  bone,  that  is  to  say  with  a 
fracture  of  the  cancellous  end  of  one  bone. 

(c)  A  wound  of  the  joint  with  a  fracture  of  the  com- 
pact layer  of  the  epiphysis,  that  is,  a  fracture  not 
interrupting  its  continuity.  In  these  cases  there  are 
sometimes  fissures  and  multiple  jagged  splinters. 

{d)  An  articular  fracture  properly  so  called,  single 
or  multiple  ;  here  the  bony  lesions  vary  very  much 
according  to  the  epiphysis  affected  and  the  circum- 
stances governing  the  impact  of  the  projectile.  In  the 
case  of  the  upper  end  of  the  humerus  there  may  be  a 
simple  separation  of  the  head,  or  complete  destruction 
of  it,  a  frequent  type  ;  at  the  elbow  there  is  often  a 
T-shaped  fracture  with  irregular  fissures,  recalhng 
in  certain  points  the  fractures  of  civil  practice  ;  the 
articular  fragment  is  often  lar^e,  the  shaft  being 
pointed  like  the  mouth-piece  of  a  fiute.  In  the  ulna, 
besides  a  transverse  fracture  of  the  olecranon,  com- 
plete crushing  of  the  bone  into  small  fragments  is  met 
with.  The  same  thing  may  occur  in  the  head  of  the 
radius  where  large  spHnters  are  rare. 

In  the  hip,  crushing  of  the  trochanter,  with  fissure 
through  the  neck,  or  separation  of  the  head  of  the 
bone  is  frequent. 

In  the  knee,  simple  fracture  of  one  condyle  or  a 
T-shaped  fracture  (figs.  2  and  4)  of  the  femur  may  be 
found  ;    in  the  tibia,  it  is  common  to  find  extensive 


10      THE  TREATMENT  OF  FRACTURES 

crushing  of  the  cancellous  tissue  with  pulverisation  of 
bone,  but  without  large  splinters  or  radiating  fissures 
(fig.  3).  Radiating  fissured  fractures  are  especially 
often  met  with  in  the  lower  extremity  of  the  humerus, 
in  the  ulna,  the  hip,  and  the  lower  end  of  the  femur. 

(e)  Complete  crushing  of  the  articular  end. 

This  classification  makes  it  clear  that  one  standard 
method  of  treatment  is  not  appUcable  to  all  cases. 

But  the  fundamental  principles  of  treatment  remain 
irrefutable  ;  they  are  those  which  govern  the  entire 
treatment  of  war-wounds,  that  is  to  say,  the  necessity 
of  a  primary  clearing  operation,  performed  as  early 
as  possible,  removing  missiles,  fragments  of  clothing 
and  organic  debris  on  its  way  to  rapid  decomposi- 
tion. There  can  be  no  question  as  to  the  absolute 
urgency  of  these  preventive  incisions,  which  are  pro- 
phylactic against  sepsis  and  are  the  basis  of  all  con- 
servative surgery. 

This  clearing  out  by  incision  ought  to  be  complete, 
extend  to  all  the  injured  parts,  and  leave  nothing 
doubtful  behind. 

In  practice  there  are  still  differences  of  opinion  upon 
the  best  way  of  carrying  it  out  and  the  extent  to  which 
it  should  go. 

We  have  the  choice  of  four  methods — viz.  arthro- 
tomy,  removal  of  bony  fragments  from  the  joint 
(esquillectomy),  resection,  and  amputation. 

These  operations  are  in  no  way  opposed  to  one 
another  ;  each  has  its  indications,  which  are  deter- 
mined by  the  extent  and  nature  of  the  injury  as  deter- 
mined by  radiography  and  by  exploration.  On  the 
other  hand,  the  indications  vary  according  to  the  time 
that  has  elapsed  since  the  infliction  of  the  wound  and 
according  to  its  situation. 

A.  Primary  Operations  (during  the  first  twelve  hours). 
— ^Theoretically  we  may  say  that  to  effect  with  certainty 
the  necessary  prophylaxis  and  to  make  sure  of  a 
definite    orthopaedic    result,    it   is   necessary   in   the 


GENERAL   CONSIDERATIONS 


11 


first  twelve  hours  to  extract  the  missile,  to  remove 
fragments  from  simple  parietal  frac^ares,  to  resect 
those  fractures  which  interfere  with  the  mechanics  of 
the  joint,  and  to  amputate  for  conditions  in  which 
the  damage  is  incompatible  with  the  ultimate  satisfac- 
tory functional  restoration  of 
the  limb. 

In  practice  these  are  the  rules 
which  ought  to  be  applied  as 
soon  as  possible,  certainly  within 
twenty-four  hours. 

{a)  Missiles  within  the  joint 
must  he  removed. — There  are  no 
doubt  some  which  remain  clini- 
cally aseptic,  but  they  are  quite 
the  exceptions.  As  a  rule,  a 
sphnter  of  a  shell  or  grenade, 
carrying  with  it  debris  of  cloth- 
ing, is  followed  with  certainty 
by  a  rapidly  spreading  acute 
arthritis.  The  infection  intro- 
duced into  a  closed  cavity  is 
very  formidable,  and  a  fatal 
result  often  follows.  In  short, 
the  presence  of  a  missile  in  a 
joint  is  always  dangerous.  Its 
removal  is  quite  the  opposite. 

Simple  opening-up  of  the 
wound  is  not  sufficient  to  ehmi- 
nate  all  chance  of  sepsis  ;  drain- 
age certainly  diminishes  the  immediate  risk  of  its 
development,  but  unless  the  missile  be  removed,  the 
degree  of  infection  is  only  lessened  and  the  patient 
remains  a  prey  to  slow  septicaemia  which  is  some- 
times fatal. 

(b)  The  area  of  a  'parietal  fracture  should  he  excised. — 
Every  bone  which  is  fissured  or  frayed  at  the  edge 
and  all  crushed  cancellous  tissue  ought  to  be  treated 


Fig.  1. — Wound  of  the 
joint  with  parietal  frac- 
ture not  interrupting  the 
continuity  of  the  epiphy- 
sis and  amenable  to 
a  limited  esquillectomy 
after  removal  of  the 
projectile. 


12  THE   TREATMENT  OF  FRACTURES 

by  scooping  out  the  bone  and  removing  the  bony 
splinters  ;  on  the  points  of  these,  even  after  extraction 
of  the  missile,  minute  organic  particles  and  threads 
of  clothing  material  are  held  up,  and  the  develop- 
ment of  a  focus  of  osteitis  is  a  grave  matter.  This 
osteitis  is  the  more  dangerous  as  bony  fissures  often 
radiate  from  the  point  which  was  struck,  and  the 


Fig.  2. — Fracture 
of  one  condyle  requir- 
ing, in  view  of  future 
orthopaedy,  resection 
of  the  knee-joint 
through  the  epiphy- 
ses. 


Fig.  3. — Fracture 
of  one  condyle  of  the 
tibia  requiring,  in 
view  of  future  ortho- 
paedy, resection  of 
the  knee-joint 
through  the  epiphy- 
ses. 


Fig.  4. — T-shaped 
fracture  of  the  lower 
end  of  the  femur  re- 
quiring typical  resec- 
tion of  the  knee- 
joint. 


sepsis  travels  along  these.  As  a  result,  infection  of  the 
bone  marrow  occurs  which  amputation  alone  is  able 
to  remedy. 

(c)  A  fracture  that  ivill  permanently  interfere  with  the 
functions  of  a  joint  should  be  treated  by  immediate  re- 
section, chiefly  because  that  operation  in  the  very  early 


GENERAL  CONSIDERATIONS  13 

period  guards  against  infection  ;  and  also  because  it 
provides  for  the  future  usefulness  of  the  joint  except 
in  the  case  of  the  knee,  where  ankylosis  ought  to  be 
systematically  aimed  at  ;  elsewhere  it  assures  satis- 
factory if  not  entire,  recovery  of  function,  while  at  the 
knee  it  is  the  only  measure  that  assures  a  position  of 
the  Umb  which  is  fundamentally  necessary  to  walking 
(figs.  2-4). 

But  for  this  purpose  resection  must  be  as  true  to 
type  as  possible  :  it  ought  not  to  be  merely  a  question, 
as  it  often  is,  of  the  mere  level  of  the  bone  sections. 
The  typical  operation  is  that  derived  directly  from 
the  teaching  of  OlUer,  and  deals  with  the  joint  without 
sacrificing  the  tendons,  carefully  separates  the  perios- 
teal prolongation  of  the  capsule  without  dividing 
Hgaments  or  tendons,  and  is  followed  by  a  most  strict 
post-operative  treatment. 

{(1)  A  fracture  of  the  loioer  Umb  extending  as  far  down 
the  shaft  as  it  does  towards  the  epiphysis  should  be  treated 
by  amputation,  because  a  cure  is  difficult  to  obtain  by 
conservative  methods  and  would  be  followed  by  a  very 
bad  functional  result  (fig.  5). 

In  the  upper  limb  amputation  is  to  be  avoided  at 
any  price  short  of  extensive  excision  of  bone,  however 
little  hope  there  is  of  preserving  a  useful  hand. 

To  these    general  statements  we    may  add  that : 

(a)  Arthrotomy  in  the  early  stage  ought  to  be  only  an 
exploratory  procedure  followed  by  extraction  of  the 
missile,  which  should  be  locahsed  if  possible.  The 
best  method  of  locaUsation  would  appear  to  be  Hirtz's 
"  compasses,"  when  there  is  time  to  employ  them  ; 
if  stress  of  work  will  not  allow  of  this,  the  position  of 
the  projectile  should  be  ascertained  by  radioscopy, 
marked  on  the  surface,  and  the  joint  widely  opened. 
If  radioscopy  is  not  available,  an  exploratory  arthro- 
tomy should  be  performed  so  as  to  admit  of  removal. 

(6)  Esquillectomy  {removal  of  the  fragments)  will  be 
added   to  arthrotomy  whenever  the  bony  lesion  is 


14      THE   TREATMENT.  OF  FRACTURES 


confined  to  the  surface  of  the  bone.  It  should  be  done 
by  a  rugine  followed  by  a  curette.  If  the  fracture  is 
more  extensive  than  at  first  appeared  or  than  is 
indicated  by  radioscopy,  if,  for  example,  there  be  deep- 
seated  cancellous  crushing  of  one  of  the  condyles  of 

the  femur,  one  would  perform 
immediate  resection;  "  esquil- 
lectomy  "  *  is  only  of  use  in  the 
small  parietal  fractures.  They 
are,  in  my  opinion,  the  only 
cases  suited  for  this  method. 

Many  surgeons  take  a  different 
line  :  arthrotomy  with  esquil- 
lectomy  is  with  them  the  treat- 
ment of  choice  for  almost  all 
fractures  into  joints,  because  it 
appears  to  be  the  most  conser- 
vative method.  They  contrast 
it  with  resection,  which  they  say 
gives  bad  results  and  look  upon 
as  a  mutilating  operation.  Ac- 
cording to  their  view,  arthro- 
tomy is  done  to  drain  an  area 
that  esquillectomy  has  cleared 
out.  Thus  presented,  the  paral- 
lel is  absurd  ;  each  operation 
has  a  precise  field  of  its  own, 
which  cannot  be  departed  from  without  falsifying  the 
results  and  the  indications. 

In  the  early  stages  of  these  war-wounds  arthrotomy 
ought  not  to  be  done  to  drain,  but  to  explore,  so  that 
the  surgical  sterilisation  of  the  wound  may  be  ensured 
by  the  removal  of  foreign  bodies  ;  if  the  missile  in 
its  passage  has  caused  a  partial  fracture,  a  gutter  or 
furrow  on  the  articular  end,  if  it  has  detached  a  frag- 


FiG.  5. — Fraeture  of 
shaft  and  epiphysis  ne- 
cessitating amputation. 


*  The  term  "  esquillectomy  "  will  be  used  throughout  this  trans- 
lation instead  of  the  more  cumbrous  term  "removal  of  splinters  of 
bone." — Ed. 


GENERAL   CONSIDERATIONS  15 

ment  or  splinters  of  bone,  the  removal  of  these  also 
is  indicated  ;  and  the  same  is  the  case  when  the 
missile  has  embedded  itself  in  the  bone  and  has  pro- 
duced in  it  a  crush-fracture.  But  whenever  there 
is  definite  solution  of  the  continuity  of  an  epiphysis, 
esquillectomy  ought  to  give  place  to  resection.  One 
can  doubtless  recall  some  brilHant  results  from  Hmited 
intra-articular  esquillectomy  in  these  complex  cases, 
but  these  will  always  be  exceptional  results  obtained 
under  favourable  circumstances  :  the  method  is  dan- 
gerous, because  patients  in  great  numbers  cannot  all 
receive  the  strict  supervision  which  is  imperative 
for  success  ;  besides,  the  final  orthopaedic  result  of  these 
partial  operations  is  generally  bad. 

(c)  Subperiosteal  resection  is  the  method  of  choice 
for  comminuted  epiphysial  fractures  Hkely  to  unite 
badly,  and  for  all  those  that  interfere  with  the 
mechanics  of  the  joint.  If  done  early,  it  is  the  typical 
operation  for  the  prophylactic  clearing-out  which 
anticipates  all  sepsis  and  ensures  aseptic  results.  When 
done  according  to  the  subcapsular-periosteal  method, 
it  gives  remarkable  results.  It  is  used  more  freely  in 
some  regions  than  in  others  ;  at  the  shoulder  it  will 
sometimes  be  possible  to  do  without  it,  subcartilagi- 
nous  excision  giving  very  favourable  results.  At  the 
elbow,  at  the  knee,  at  the  ankle,  and  in  the  metatarsus 
it  should,  however,  always  be  employed  ;  in  these 
situations  it  is  the  ideal  conservative  operation. 

{d)  Immediate  amputation  ought  only  to  be  chosen 
in  exceptional  cases,  unless  there  is  crushing  of  the 
bones  with  irreparable  injury  to  the  muscles,  vessels, 
and  nerves. 

In  the  upper  hmb  it  ought  never  to  be  performed 
primarily  whatever  the  extent  of  the  injury,  because 
subperiosteal  resection  and  extensive  esquillectomy 
always  suffice  to  deal  with  even  the  greatest  damage. 

In  the  lower  limb  it  is  performed  sometimes  after 
direct  exploratory  examination. 


16      THE  TREATMENT  OF  FRACTURES 

Whatever  may  be  the  state  of  the  elbow  or  the 
shoulder,  a  normal  Tiand  with  mobile  fingers  is  always 
of  more  use  than  a  hook  on  the  forearm.  In  the 
lower  limb,  on  the  contrary,  the  conditions  may  be 
such  that  an  artificial  leg  is  much  better  than  a  con- 
siderably shortened  leg  or  thigh.  One  can  hardly 
define  these  conditions  in  words  ;  it  is  largely  a  ques- 
tion of  degree.  Three  factors,  however,  dominate  the 
decision  : 

If  the  lesions  of  the  soft  parts  are  very  extensive, 
if,  in  short,  preservation  of  the  limb  appears  too 
hazardous,  immediate  amputation  should  be  done. 

If  the  bony  lesions  are  too  extensive  for  the  func- 
tional power  to  be  ultimately  restored,  one  would 
amputate  at  once  ;  in  practice,  any  injury  may  be 
considered  as  too  extensive  that  would  entail  a  short- 
ening of  at  least  4  inches. 

When  there  is  a  great  influx  of  wounded,  amputa- 
tion should  be  chosen  unless  the  case  appears  very 
favourable  for  resection  ;  conservative  surgery  requires 
diligent  post-operative  supervision,  much  time  and 
care.  Without  them  it  is  dangerous  and  apt  to  lead 
to  disappointing  results. 

B.  Secondary  Operations  (in  the  febrile  period). — 
In  these  cases  there  is  no  longer  any  question  of  prac- 
tising prophylactic  operations  upon  damaged  areas 
threatened  with  imminent  sepsis,  but  of  ensuring  drain- 
age and  rapid  disinfection  of  an  already  infected  joint. 
The  decision  as  to  the  operative  measures  best  fitted 
for  this  purpose  is  guided  by  the  question  of  the  resist- 
ance of  the  individual  patient  ;  the  longer  the  time 
since  the  commencement  of  the  sepsis,  the  more  radical 
should  the  measures  be,  and  the  less  the  rehance  that 
should  be  placed  upon  drainage  without  removal  of 
bonfe. 

(1)  Arthrotomy  is  suited  to  pure  synovial  injuries, 
to  drain  abscesses,  and  to  remove  if  possible  the  foreign 
bodies  causing  the  trouble.      It  is  useful  for  joints 


GENERAL   CONSIDERATIONS  17 

with  loose  capsules  and  large  synovial  cavities.  It  only 
drains  close-fitting  joints  like  the  elbow  and  the  hip 
indifferently.  It  is  only  successful  in  cases  of  joint 
suppuration  due  to  superficial  osteitis  that  easily  finds 
its  way  to  the  surface.  It  should  be  employed  for  the 
shoulder  and  the  knee,  elsewhere  it  is  not  worth  while 
wasting  time  upon  it ;  the  less  so  since  the  usual  result 
of  these  suppurations  is  ankylosis,  and  it  is  therefore 
better  to  resect  at  once,  especially  where  articular 
mobiHty  is  desirable,  as  for  example  in  the  elbow. 

(2)  Resection  is  a  method  of  drainage  only  in 
the  close-fitting  joints.  In  severe  infections  without 
fracture  it  performs  marvels  at  the  elbow,  the  wrist, 
the  hip,  the  ankle,  and  the  tarsal  joints.  Often  useless 
at  the  shoulder,  it  is  equally  so  at  the  knee,  since  it 
leaves  no  cavity  for  drainage.  In  simple  suppurating 
arthritis  of  the  knee,  without  injury  to  bone,  if  arthro- 
tomy  with  extraction  of  the  missile  does  not  lead  to 
rapid  improvement  of  the  general  and  local  phenomena, 
and  if  at  the  end  of  three  or  four  days  the  condition 
is  still  critical,  resection  is  useless  and  even  dangerous. 
Perhaps  excision  of  the  synovial  membrane  might  be 
of  value  :  I  do  not  recommend  it  since  I  have  no  expe- 
rience of  it,  and  until  we  have  more  knowledge  on  the 
point  we  must  resign  ourselves  to  rapid  amputation. 

It  is  quite  a  different  matter  when  there  is  a  fracture. 
The  infection  is  then  rather  an  osteomyelitis  than  an 
arthritis,  and  it  is  safer  to  resect  at  once,  even  at  the 
knee,  to  get  rid  of  the  infection.  Undoubtedly  failures 
will/)ccur,  but  there  will  also  be  remarkable  successes. 
My  advice  is  to  use  it  immediately  for  any  joint  unless 
the  injury  is  parietal  or  extra-articular. 

(3)  Immediate  amputation  is  called  for  when  the 
patient's  general  condition  is  profoundly  lowered, 
when  there  are  purulent  sinuses  everywhere,  and  when 
there  are  multiple  infected  wounds  ;  in  short,  when 
the  patient  obviously  requires  to  be  rid  at  once  of  the 
source  of  the  infection. 


18      THE  TREATMENT  OF  FRACTURES 

Secondary  amputation  should  be  done,  without  too 
great  loss  of  time,  for  injuries  of  the  knee  after  the 
failure  of  arthrotomy  or  resection,  the  risk  of  the 
septicaemia  being  then  only  too  apparent.  In  the  case 
of  the  ankle  and  the  upper  limb  an  attempt  to  pre- 
serve the  limb  by  resection  can  be  persisted  in  much 
longer  without  danger. 

in.  General  Technique  of  Operations  upon  the  Joints 

The  operations  which  are  performed  on  the  joints, 
being  essentially  conservative,  require  great  precision 
and  much  attention  to  detail  from  beginning  to  end. 
The  different  operative  stages  should  be  conservative, 
in  order  that  the  final  result  may  be  preservation.  It 
is  a  fundamental  precept,  never  to  be  forgotten,  that 
whenever  an  attempt  is  made  to  obtain  recovery  of 
function,  none  of  the  elements  of  strength  and  mobihty 
in  a  joint  must  be  sacrificed. 

This  precept  imposes  two  rules  of  technique  which 
ought  to  be  regarded  as  dogmatic. 

The  exploratory  incisions  should  not  sacrifice  any 
tendon,  muscle,  or  muscular  nerve-supply. 

The  opening  up  of  bony  cavities  ought  to  be  done  with 
the  sharp  rugine,  ivhich  not  only  separates  the  periosteum, 
but  raises  with  it  the  capsular  ligaments  and  tendinous 
insertions,  thus  leaving  intact  all  the  working  apparatus 
of  the  joint. 

I  place  on  record  these  two  precepts  of  Olher's 
conservative  surgery  because  many  surgeons  do  not 
know  them  or  have  not  understood  the  bearing  of  them, 
which  will  explain  the  want  of  functional  success  which 
is  wrongly  attributed  to  resection.  These  surgeons 
have  regarded  the  preservation  of  the  periosteum  as 
the  only  point  in  Ollier's  method,  and  since  the  osteo- 
genetic  power  of  the  periosteum  is  not  always  neces- 
sary, and  as  from  this  point  of  view  it  is  possible 
at  times  to  do  without  it,  they  have  concluded  that 


GENERAL   CONSIDERATIONS  19 

its  separation  is  a  useless  complication,  and  have 
returned  to  their  former  extra-periosteal  (parosteal) 
methods. 

This  is  an  absolute  misapprehension  of  the  conser- 
vative method,  as  we  shall  see. 

1.  Physiological  Incisions. — ^In  1885  OlHer  wrote 
as  follows  :  "  The  object  is  to  preserve  all  the  tissues, 
all  the  elements  essential  for  the  reconstitution  of  the 
bones  and  the  joints,  while  causing  the  least  possible 
damage  to  the  peripheral  organs.  To  attain  this  end 
we  must  do  our  operations  by  methods  different  from 
those  in  ordinary  use.  One  should  approach  a  joint 
in  the  same  manner  ias  one  approaches  an  artery, 
namely,  through  carefully  planned  incisions.  There 
is  no  longer  any  call  for  rapidity  in  opening  a  joint : 
it  should  be  approached  by  way  of  the  muscular 
interspaces  without  injuring  any  structure  not  only 
important,  but  merely  useful,  and  without  sacrificing 
any  of  the  requirements  of  a  sound  operation,  such  as 
room  for  the  operator  and  space  for  the  movement  of 
his  instruments." 

These  intermuscular  incisions  are  made  only  in 
certain  well-defined  anatomical  situations  when  an 
arthrotomy  or  resection  is  in  question.  The  incision 
appropriate  for  each  joint,  "  the  physiological  incision,^' 
is  given  farther  on  ;  it  is  the  incision  chosen  with  due 
consideration  for  the  future  physiological  function  of 
the  joint. 

In  war-wounds  it  may  seem  impracticable  to  follow 
these  lines  :  one  will  often  be  tempted  to  utiHse  the 
openings  made  by  the  missile.  Whenever  these  are 
not  gaping  holes,  however,  it  will  be  an  advantage  to 
approach  the  joint  by  the  correct  route  and  to  utilise 
the  track  of  the  missile,  after  it  has  been  duly  cleaned 
up,  as  a  route  for  draining,  and  not  as  a  means  of 
access.  That  is  a  question  of  dexterity  and  common 
sense  which  cannot  be  reduced  to  rules .  If  it  is  decided 
to  utilise  the  existing  wound,  its  walls  ought  to  be 


20  THE   TREATMENT  OF  FRACTURES 

excised  with  a  bistoury  so  as  to  transform  it  into  a 
passage  with  clean  sides  without  unduly  sacrificing 
healthy  muscular  tissue.  Muscles  and  tendons  ought 
not  to  be  divided  transversely  by  joining  the  two 
openings  of  a  sinus  ;  in  the  case  of  the  shoulder  particu- 
larly, division  of  the  deltoid  is  disastrous.  In  a  word, 
a  joint  ought  always  to  be  approached  with  a  full 
regard  to  its  future  movements. 

2.  Preservation  of  the  Capsulo-periosteal 
Sheath. — ^This  ought  to  be  preserved,  for  two,  reasons  : 
first,  to  retain  the  elements  essential  for  regeneration 
of  bone,  which  is  the  anatomical  aim,  so  to  speak  ; 
second,  to  maintain  intact  the  factors  concerned  in  the 
stability  and  mobility  of  the  joint,  the  physiological 
aim. 

(a)  The  whole  thickness  of  the  periosteum  with  its 
deep  osteogenetic  layer  ought  to  be  preserved  because, 
thanks  to  its  activity,  the  bony  extremities  are  regen- 
erated. 

What  happens  after  a  resection  ? 

At  each  end  of  the  capsulo-periosteal  sheath  at  its 
periosteal  edge,  the  osteogenetic  layer  proHferates, 
thickens,  and  gives  rise  to  masses  of  soft  consistence 
and  cartilaginous  appearance,  in  which  ossification 
occurs.  Two  masses  of  new  bone  result,  which  soon 
constitute  new  articular  extremities  between  which  a 
new  joint  is  formed. 

(&)  The  capsular  sheath  ought  to  be  preserved 
because  one  thus  retains  inside  it  a  certain  number  of 
endothehal  cells  which  favour  the  creation  of  a  new 
synovial  membrane,  and  outside  it  the  necessary  Hga- 
mento-tendinous  continuity. 

Let  us  consider  first  the  formation  of  a  new  synovial 
membrane. 

At  the  edge  of  the  capsular  portion  where  the  syno- 
vial membrane  exists,  the  serous  layer  thickens  under 
the  influence  of  traumatisin  ;  its  endothehal  layer  sends 
out  cellulo-vascular  processes  which  meet  one  another 


GENERAL   CONSIDERATIONS  21 

and,  blending  together,  form  what  will  become  later 
the  articular  cavity. 

If  the  wound  does  not  suppurate,  or  only  does  so 
sUghtly,  we  have  at  hand  all  the  elements  necessary 
for  that  gliding  motion  which  it  is  the  object  of  gentle 
movement  to  promote  during  the  early  stages  of  the 
organisation  of  the  wound.  Little  by  little,  under  the 
influence  of  these  movements,  the  endothelial  lacunae 
enlarge,  the  partitions  wear  away  and  disappear,  and 
finally  a  new  synovial  membrane  is  formed  :  that  is  the 
ideal  plan  of  development. 

When,  on  the  contrary,  inflammation  or  operative 
measures  have  destroyed  these  synovial  elements,  it  is 
much  more  difficult  to  form,  by  means  of  repeated 
gliding  movements,  a  sort  of  hygroma,  or  an  inter- 
osseous serous  bursa,  and  this  is  always  less  perfect 
and  less  adapted  to  its  purpose  than  is  the  true  synovial 
membrane  in  the  former  case.  After  this  explanation 
it  is '  easy  to  understand  why  technique  and  post- 
operative care  play  an  essential  role  in  the  final  results 
of  resection  if  we  regard  them  from  the  point  of  view 
of  restoration  of  function.  It  is  for  want  of  under- 
standing of  this  anatomico-physiological  development 
of  new  joints  that  some  surgeons  only  get  bad  results 
and  therefore  condemn  resection. 

If  the  preservation  of  the  synovial  membrane  and 
its  regeneration  play  a  large  role  in  the  post-operative 
formation  of  a  new  joint,  it  is  the  preservation  of  the 
whole  tendino-Hgamentous  capsule  of  the  joint,  and 
the  retention  of  the  muscular  insertions  in  their  normal 
relations  to  the  capsulo-periosteal  sheath,  which  causes 
the  gradual  development  of  the  new  joint  towards  the 
perfect  physiological  type. 

The  capsulo-periosteal  sheath  placed  in  immediate 
contact  with  the  bone  acts  at  first  like  a  guardian  to 
the  process  of  osteogenesis  ;  it  limits  the  new  formation 
of  bone,  restrains  it,  and  maintains  it  in  good  position  ; 
then  at  the  proper  time  it  models  it  under  the  action 


22      THE   TREATMENT  OF  FRACTURES 

of  the  muscles,  which,  having  retained  their  insertions 
into  the  part  of  the  capsule  corresponding  to  the 
epiphysial  tuberosities,  remain  in  their  normal  position 
and  contract  as  usual.  By  their  normal  action  they 
press  on  the  capsule  and  make  their  impress  through 
it  on  the  newly  formed  bone.  In  other  positions  they 
pull  upon  and  mould  the  soft  bone  into  shape.  In 
short,  their  action,  which  is  retained  intact  by  the  pre- 
servation of  the  capsular  sheath,  is  constantly  tending 
towards  the  production  of  a  physiologically  normal 
joint. 

The  careful  separation  of  the  capsular  sheath  is 
even  more  indispensable  when  the  injuries  are  so 
extensive  that  it  might  seem  useless  to  take  all  this 
care.  Here,  the  preservation  of  the  tendinous  inser- 
tions in  the  capsulo-periosteal  sheath  assures  the  func- 
tions of  the  muscles,  permits  the  secondar}^  drawing 
together  of  the  widely  separated  bones,  and  rearticu- 
lates  them  in  some  measure  ;  the  capsule  then  acts  as 
an  elongated  tendon,  and  it  is  by  its  means  that  one  is 
able  to  obtain  excellent  functional  results  in  many 
extensive  resections. 

It  is  unnecessary  to  labour  this  point  further. 

What  are  the  necessary  steps  in  practice  to  preserve 
these  indispensable  factors  for  recovery  of  function  ? 

After  the  joint  has  been  opened,  as  described,  and 
the  intermuscular  intervals  kept  apart  by  retractors, 
it  is  necessary  first  to  incise  the  capsule  in  the  direction 
of  its  fibres,  or  the  long  axis  of  the  limb.  When  that 
is  done,  the  knife  is  abandoned  for  the  nigine,  which 
should  be  used  throughout  the  rest  of  the  operation. 
This  rugine  should  be  of  a  special  pattern  :  for  separating 
the  periosteum  and  its  sheath  there  is  only  one  good 
one,  that  of  OlHer,  with  a  steel  shaft  ending  in  a  flattened 
extremity,  as  sharp  as  a  razor.  This  cutting  edge  is 
bevelled  from  its  dorsal  surface  downwards  towards 
the  under  edge  which  is  kept  in  contact  with  the 
bone  (fig.  6). 


GENERAL   CON  til  DERATIONS 


23 


which  Oilier 


i\  I 


A.J 


ill 


With  this  instranient,  wiiiclj  lias  a  solid  handle,  a 
way  is  made  by  degrees  between  the  bone  and  the 
periosteum,  and  one  is  able  to  raise  the  periosteum 
and  the  capsule  bit  by  bit,  and  to  preserve  intact  a 
fibro-periosteal  prolongation  of  the  muscles  and 
tendons.  The  name  ''  detaclie-tendon 
gave  to  this  instru- 
ment indicates  the  r;::^^  ^ 
object  in  view.  But  !l.  I  i 
in  order  to  attain  it  |.^^J  M 
without  accidents,  ^^m  |ij 
the  rugine  must  be  ^^f^  |||| 
used  slowly  and  for- 
cibly, the  right  hand 
being  guided  by  the 
left  index  finger  ap- 
phed  to  tile  right. 
With  a  little  practice 
it  is  possible  to  de- 
nude the  most  ir- 
regular tuberosities 
so  that  finally  the 
bone  will  be  as  fret 
as  if  it  had  been 
enucleated  from  its  fibrous  .sheath.  This  method  is 
appHed  to  each  fragment  of  bone  whicli  is  more  or 
less  free.  Every  little  fragment,  however  small,  ought 
to  be  treated  thus  ;  it  should  be  grasped  in  forceps 
and  its  external  surface  carefully  stripped.  It  is  only 
in  this  way  that  the  subperiosteal  operation  can  be 
truly  and  typically  carried  out. 

A  final  detail  will  perhaps  be  useful :  as  one 
approaches  the  shaft,  the  separation  of  the  periosteum 
becomes  easier.  Sometimes  a  careless  movement  causes 
the  shaft  to  project  through  the  separated  sheath. 
This  is  an  accident  which  is  most  likely  to  occur  in 
resection  of  the  elbow  when  the  separation  is  being 
carried    above   the    condyles   of   the    humerus,  espe- 


m 


Fig.  G. — Ollier's  rugiiies  with  cut- 
ting edge  for  the  complete  detachment 
of  the  deep  layer  of  the  periosteum,  the 
ligaments,  and  tendinous  insertions. 


24       THE  TREATMENT  OF  FRACTURES 

cially  in  secondary  operations  :  it  can  be  avoided  by 
care. 

3.  Division  of  the  Bone. — ^In  resections  it  is  often 
remarked  that  it  is  difficult  to  steer  a  correct  course 
and  remove  enough  bone  to  procure  mobihty  without 
removing  too  much  to  preserve  a  sufficiently  firm  joint. 
The  best  sections  are  those  made  through  the 
epiphysial  ends.  It  is  much  more  frequently  possible 
to  do  this  than  one  would  think.  When  these  injuries 
are  limited,  there  is  sometimes  difficulty  in  making 
the  bone  project  sufficiently  to  divide  it,  and  the 
surgeon  may  be  tempted  to  prolong  the  denudation 
further  towards  the  shaft  :  this  is  useless,  and  gives 
very  little  more  room.  The  difficulty  is  caused  by 
the  periosteal-ligamentous  adhesions,  and  should  be 
overcome  by  again  applying  the  rugine  to  each  tuber- 
osity, and  stripping  off  these  structures  transversely 
instead  of  axially.  A  chain  saw,  or  Gigli's  saw,  can 
then  be  used,  and  the  epiphysis  divided  at  a  suitable 
level. 

When  the  injury  is  more  extensive  and  runs  along 
the  shaft,  there  is  no  need  to  conclude  that  the  con- 
servative operation  is  doomed  to  fail  to  restore  the 
function  of  the  joint,  and  should  be  rejected.  In 
the  majority  of  these  cases  the  fracture  in  the  shaft 
runs  parallel  to  the  long  axis  of  the  bone  ;  a  large 
fragment  comprising  the  articular  end  and  a  part  of 
the  shaft  is  detached,  but  there  is  no  actual  solution 
of  continuity  of  the  shaft  itself.  The  pointed  end 
of  the  latter  reaches  down  to  the  level  of  the  broken 
epiphysis,  and  the  saw  has  only  to  remove  this  sharp 
extremity.  If  the  periosteum  has  been  carefully 
preserved,  bone  formation  will  result,  and  a  new 
epiphysis  will  be  constituted. 

In  a  number  of  cases  the  epiphysis  is  only  fractured 
on  one  side  ;  the  broken  fragment  comprises  a  thin 
shell  of  the  shaft  which  is  of  no  importance  ;  enough 
of  the  articular  end  remains  on  the  opposite  side  for 


GENERAL   CONSIDERATIONS 


25 


a  unilateral  intra-epiphysial  section  to  be  made 
which  is  sufficient  if  the  periosteum  has  been  pre- 
served. 

When  both  epiphyses  are  destroyed  [i.e.  T-shaped 
fracture),  it  is  customary  to  find  fissures  extending  up 
the  medullary  canal  of  the  shaft.  Unless  resection  is 
performed,  these  parallel  fissures   constitute   a   very 


Fig.  7. — Fracture  of  the  el- 
bow by  shell-splinters.  Total 
resection  of  the  elbow- joint  on 
the  second  day,  in  consequence 
of  the  fissured  shaft  of  the  ulna. 


Fig.  8. — The  same  case  as 
fig.  7.  Radiograph  fifteen  days 
after  resection. 


great  danger  if  the  bone  becomes  infected,  because 
it  is  thus  that  acute  osteomyehtis  arises.  If,  however, 
the  intra -articular  fragments  are  removed,  and  the 
wound  is  systematically  cleaned,  they  frequently 
weld  together  and  reconstitute  the  shaft  (figs.  7-9). 
There  is  no  need  for  anxiety  in  these  cases  :  the  bone 
section  should  be  performed  as  if  the  fissures  did  not 
exist. 

If  the  fracture  is  clearly  as  much  epiphysial  as  dia- 
physial, with  its  centre  at  the  line  of  junction,  it  must 


2o      THE   TREATMENT  OF  FRACTURES 


be  realised  that  this  injury  often  leads  to  amputation 
if  resection  is  not  performed  at  once.  But  the  opera- 
tion ought  to  have  for  its  object  the  preservation  of 
a  large  portion  of  the  lower  fragment  of  the  shaft, 
which  is  nearly  always  pos- 
sible. The  articular  end 
is  removed  and  the  Hmb 
carefully  immobilised  in  p 
suitable  position  for  five  or 
•six  weeks,  so  that  bony 
union,  which  is  accelerated 
by  the  operative  measures, 
may  occur  in  the  fractured 
shaft.  Then,  but  then  only, 
attempts  at  movement  may 
be  made  if  mobility  is  de- 
sired. 

Thus,  resection  in  certain 
cases  is  an  operation  true 
to  type,  in  others  it  con- 
sists in  removal  of  all  the 
epiphysial  fragments,  sub- 
periosteally  of  course,  fol- 
lowed by  trimming  with  the 
saw. 

When  the  articular  end  of 
one  hone  only  is  affected, 
should  resection  he  confined 
to  that  hone  ? 

This  is  the  usual  proce- 
dure in  certain  situations  ; 
hemi-resection  of  the  upper 
end  of  the  humerus  is 
commonly   called  resection 

of  the  shoulder,  and  femoral  hemi-resection  resection 
of  the  hip.  In  mihtary  surgery,  the  classical  method  is 
adhered  to  at  the  hip  and  shoulder  if  one  bone  only 
is  injured,  because  it  is  sufficient  to  ensure  good  post- 


FiG.  9. — The  same  case  as 
figs.  7  and  8.  Radiograph  at 
the  end  of  two  months.  The 
wound  was  healed  by  the 
thirty-ninth  day ;  active  flexion 
had  then  almost  reached  a 
right  angle.  At  the  end  of  a 
year  the  result  is  perfect :  ac- 
tive flexion  and  extension  are 
normal ;  the  patient  can  carry 
1 5  kgs.  with  the  arm  raised  ; 
pronation  and  supination  are 
normal. 


GENERAL   CONSIDERATIONS  27 

operative  results,  and  because  the  functional  recovery 
is  better  when  it  is  so  done. 

But  in  other  situations  it  is  different.  As  a  general 
rule,  when  mobihty  is  desired,  it  is  better  to  put  into 
contact  two  bony  surfaces,  which  by  friction  will 
adapt  themselves  to  one  another,  than  to  oppose  bone 
to  cartilage,  in  which  case  the  adaptation  will  not 
be  so  good,  since  the  unmouldable  cartilage  will 
remain  as  it  is,  the  other  surface  having  to  do  all 
the  work  of  fashioning  the  joint.  At  the  elbow  this 
is  very  clear :  no  doubt  some  perfect  results  are 
obtained  from  hemi-resection,  but  more  often  the 
articular  movement  becomes  checked  at  a  certain 
stage  ;  in  the  lower  hemi-resections  of  the  elbow  [i.e. 
of  the  bones  of  the  forearm)  the  movement  of  active 
flexion  beyond  a  right  angle  can  only  be  effected 
after  a  sudden  sHde  over  the  anterior  trochlear  surface. 
In  the  superior  hemi-resections  {i.e.  of  the  humerus) 
one  never  restores  pronation  and  supination.  At  the 
elbow,  then,  it  is  better  to  do  a  total  resection,  unless 
the  loss  of  substance  in  one  of  the  two  bones  is  too 
great.  In  the  resections  where  ankylosis  is  aimed  at, 
as  at  the  knee,  there  is  great  advantage  in  bringing 
two  bleeding  bony  surfaces  into  apposition.  It  is 
illogical  to  allow  contact  between  bone  and  cartilage 
if  one  wishes  to  obtain  firm  bony  union  ;  and  be- 
sides, the  removal  of  a  thin  slice  of  cartilage  does  not 
add  greatly  to  the  loss  of  substance.  Thus,  except 
at  the  hip  and  shoulder,  a  resection  of  both  articular 
ends  should  be  the  rule. 

4.  Drainage. — ^The  best  method  of  draining  a  "joint 
which  has  not  been  resected  is  to  insert  drainage  tubes 
into  small  openings  in  the  capsule.  It  is  better  not 
to  pass  them  in  deep,  and  not  to  insert  any  transversely, 
aseptic  though  they  be,  across  a  serous  membrane 
which  does  not  tolerate  them  well.  In  the  case  of 
the  pleura,  this  rule  is  well  estabUshed  ;  in  the  case  of 
the  synovial  membrane  it  holds  equally  well. 


28      THE   TREATMENT  OF  FRACTURES 

When  the  case  is  one  of  resection  instead  of  an 
arthrotomy,  the  injuries  being  largely  exposed,  I  do 
not  as  a  rule  put  in  drainage  tubes,  but  insert  tampons 
of  aseptic  gauze  gently  without  force  or  pressure. 
Gauze  is  regarded  as  holding  up  the  discharges,  and 
many  surgeons  proscribe  it  for  that  reason.  It  is 
probable  that  they  plug  too  forcibly,  which  makes  it 
ineffective,  or  that  they  leave  the  dressings  in  place 
too  long.  These  are  questions  of  personal  practice 
which  are  not  absolute  rules.  The  principal  point  is 
to  leave  the  wound  wide  open  without '  suturing  it, 
as  A.  Poncet  always  advised  in  all  surgical  casualties. 

5.  Immobilisation.— Every  joint  that  has  under- 
gone injury  or  has  been  operated  upon  ought  to  be 
immobilised.  In  principle,  the  only  good  immobilisa- 
tion is  that  which  fixes  the  joint  above  and  that 
below,  as  A.  Bonnet  advised,  and  the  reahsation  of  this 
ideal  ought  to  be  striven  for.  After  resection,  how- 
ever, it  is  not  absolutely  necessary  everywhere  ;  thus 
in  the  case  of  the  elbow  it  is  useless  to  immobiUse  the 
shoulder  ;   but  as  a  general  rule  the  principle  holds. 

The  best  immobiUsing  agent  is  the  plaster  casing. 
I  think  that  at  first  this  method  should  always  be 
used  (except  at  the  elbow,  where  I  often  omit  it). 
Metal  splints  ought  only  to  be  used  if  there  is  no 
time  to  make  others.  It  is  only  later  on  that  the 
wire  spHnts  or  plaster-of-paris  splints  with  windows 
are  indicated.  The  former  do  not  immobiUse  as  well 
as  the  plaster  casings,  the  latter  make  it  difficult  to 
inspect  the  limb  ;  OlHer  abandpned  them  twenty-five 
years  ago.  In  spite  of  their  present  vogue  they 
should  only  be  used  sparingly  for  joint  injuries,  and 
even  then  always  only  temporarily. 

6.  Dressings  and  Sunlight  Therapy. — ^After 
primary  resection  performed  early,  the  course  of 
the  wound  is  uniformly  aseptic.  Dressings  can  and 
ought  to  be  done  seldom  ;  the  post-operative  dressing 
may  well  remain  unchanged  for  8  to   15  days.     In 


GENERAL   CONSIDERATIONS  29 

all  cases  one  can  and  ought  to  dress  the  cases  only 
occasionally  unless  sunlight  treatment  is  possible. 

After  secondary  [intra- febrile)  resections,  it  is  often 
necessary  to  do  the  first  dressing  as  early  as  the  end 
of  2  to  4  days,  but  after  this  has  been  done  it  will 
be  advantageous  to  disturb  the  wound  as  seldom 
as  possible.  I  have  seen  intra-febrile  operations  for 
the  removal  of  the  astragalus  healed  in  60  days  after 
6  dressings,  some  secondary  resections  of  the  elbow 
in  39  and  45  days  with  2  dressings  between  the  1st 
and  15th  days,  after  which  the  necessity  of  move- 
ments called  for  greater  frequency.  The  current 
fashion  then  is  few  dressings,  and,  I  would  like  to 
add,  not  voluminous  ones.  There  is  a  tendency 
to  use  too  much  wool,  to  bury  under  enormous  layers 
a  wound  which  wants  to  be  aerated,  a  skin  which  is 
best  exposed  to  the  air  and  the  sun.  A  custom  which 
is  very  expensive  and  particularly  bad  is  to  envelop 
the  limb  in  non-absorbent  wool  steriHsed  or  not. 

These  bad  practices  ought  to  be  abandoned. 

In  general  it  is  well  to  do  the  first  dressing  under 
ethyl-chloride  anaesthesia  ;  one  is  able  thus  to  remove 
the  gauze  and  replace  it  without  pain.  After  each 
dressing  strict  immobiUsation  is  renewed. 

If  the  cHmatic  conditions  allow  of  a  sun  bath,  the 
procedure  is  different :  insolation  and  a  change  of 
dressing  will  be  the  daily  rule.  In  these  circumstances 
a  yery  light  dressing  is  employed.  Those  who  have 
never  practised  hehotherapy  can  have  no  idea  of  the 
truly  magical  effect  of  the  sun  on  surface  wounds  ; 
in  a  few  minutes,  under  one's  eyes,  the  bleeding 
surface  is  entirely  modified.  A  sitting  of  a  quarter 
of  an  hour  suffices  to  get  rid  of  the  sloughs  and  after 
three  or  four  sittings  suppuration  is  at  an  end.  This 
result  is  due  to  a  regular  flow  which  occurs  from 
within  outwards.  If  the  sun  is  rather  strong,  at  the 
end  of  five  minutes  on  an  average  one  sees  the  wound 
dotted  with  red  spots  ;    at  the  end  of  seven  minutes 


30  THE   TREATMENT  OF  FRACTURES 

a  sort  of  pink  serum  exudes  having  the  appearance 
of  blood  serum ;  the  flow  is  abundant  enough  for 
one  easily  to  collect  an  appreciable  quantity  if  one 
wishes.  Then  the  wound  becomes  glazed  ;  it  takes 
on  a  fine  reddish  tint,  and  if  touched  it  bleeds.  In 
short  it  gives  the  impression  that  some  embryonic 
capillaries  are  formed  on  the  spot  in  a  few  moments, 
and  that  the  wound  is  vascularised  as  if  by  some 
intense  reaction. 

At  the  end  of  some  days  the  wound  is  considerably 
reduced  in  size  ;  cicatrisation  progresses  with  wonder- 
ful rapidity,  and  healing  is  obtained  more  quickly 
than  by  any  other  method.  But  insolation  has  yet 
another  advantage  :  under  its  action  the  muscles  do 
not  atrophy  but  they  remain  strong  and  vigorous. 
When  it  is  desired  to  re-estabUsh  movement  in  the 
joint  the  period  of  passive  movements  is  much  short- 
ened ;  the  power  of  active  contraction  is  recovered 
in  a  few  days.  I  have  seen  patients  whose  elbows 
have  been  resected  move  their  forearms  themselves 
fifteen  days  after  operation.  One  patient  at  the  end 
of  forty  days  was  able  to  lift  Ij  kilogrammes  with 
arm  extended,  and  then  to  raise  it  beyond  a  right 
angle.  Heliotherapy  is  an  expedient  no  one  should 
overlook. 

7.  Mobilisation. — If  one  does  not  deliberately  seek 
for  ankylosis,  whether  after  arthrotomy  or  resection, 
early  movement  is  the  condition  necessary  for  the 
recovery  of  the  functional  power.  But  this  ought 
not  to  be  begun  until  the  day  after  all  pain  has  dis- 
appeared ;  it  should  only  be  continued  if  the  passive 
movements  can  be  performed  without  any  acute  pain 
and  without  producing  inflammation.  There  are  no 
other  rules  than  these.  It  should  never  be  forgotten 
that  absolute  rest  and  immobility  form  the  basis  of 
all  treatment  of  inflammation.  By  not  obeying  this 
law  one  runs  counter  to  the  end  in  view. 

On  the  other  hand,  if  the  period  of  immobihty  is 


GENERAL   CONSIDERATIONS  31 

unnecessarily  prolonged,  the  formation  of  bony  anky- 
losis and  finn  ligamentous  adhesions  is  favoured.  It 
also  induces  a  muscular  atrophy  that  is  often  irre- 
mediable. It  is  not  well,  then,  to  prolong  the  period 
of  joint-rest  too  far.  But  attempts  at  movement  must 
be  made  very  gently  ;  any  undue  force  is  paid  for  by 
inflammation  which  increases  the  tendency  to  ankylosis. 
In  fine,  if  recovery  of  the  normal  function  of  a  joint 
is  sought  for  after  an  operation,  one  must  avoid  three 
dangers  :  too  prolonged  immobiUsation,  too  rapid 
mobiUsation,  and  forcible  mobiUsation.  Neglect  of 
this  is  the  explanation  of  many  failures. 

MobiUsation,  therefore,  should  be  begun  very 
gently  but  early,  subject  to  the  above  reservations 
(no  pain,  no  temperature,  no  secondary  reaction), 
even  if  there  is  much  loss  of  bone.  In  this  case  the 
muscles  have  got  to  take  the  place  of  ligaments  in  the 
new  joint  :  it  is  essential  to  preserve  them  to  the 
utmost.  But  in  the  intervals  between  the  short  trials 
of  passive  movement  there  must  be  complete  im- 
mobility with  the  bones  in  contact. 

Care  is  necessary  not  to  exceed  the  limit  :  so  per- 
suaded does  one  become  of  the  necessity  of  movements 
that  one  is  apt  to  consider  the  patient  who  does  not 
wish  them  to  be  performed  as  cowardly  or  hyper- 
sensitive. Either  they  are  imposed  upon  him  as  a 
stern  necessity,  or  they  are  done  unexpectedly,  which 
is  the  worst  of  methods.  I  have  often  witnessed  the 
deplorable  results  of  too  much  zeal.  As  Olher  has 
written,  "  If  dociUty  on  the  part  of  the  patient  should 
be  his  greatest  virtue,  patience  on  the  part  of  the 
surgeon  is  no  less  necessary.  It  is  a  mistake  to  hope 
to  obtain  in  eight  days  what  requires  several  months. 
It  is  not  a  matter  of  conquering  resistance  and  of 
breaking  down  adhesions,  but  of  favouring  the  recon- 
stitution  of  gliding  movement  and  the  regeneration 
of  an  interposed  serous  membrane.  Time  is  indis- 
pensable for  these  things.     Too  violent  or  too  pro- 


32      THE   TREATMENT  OF  FRACTURES 

longed  exercise  is  capable  of  injuring  the  tissues  which 
it  is  intended  to  make  supple,  and  of  inducing  a  plastic 
and  adhesive  process  instead  of  creating  a  sHding 
joint." 

By  adopting  these  precepts  one  is  sure  not  to  end 
either  with  ankylosis  or  with  a  fiail-joint.  The  latter, 
with  its  complete  loss  of  power  of  active  movement,  is 
primarily  due  to  complete  muscular  insufficiency  and 
bad  post-operative  management.  When  a  primary 
resection  has  been  done,  the  muscles  are  vigorous  and 
strong,  nothing  has  atrophied  them  ;  when  they 
contract,  they  press  the  articular  surfaces  closely 
together ;  they  articulate  the  new  joint  and  permit 
to  it  a  play  of  movement  of  satisfactory  ampHtude  and 
precision,  even  if  the  resection  has  been  very  extensive. 
Doubtless  in  war-wounds  one  should  not  look  for  the 
ideal  anatomical  result  of  the  resections  performed  in 
peace-time  with  their  perfect  restoration  of  the  bony 
extremities  in  their  normal  position  bound  together 
by  a  marvellously  regular  ligamentous  apparatus  ; 
but  the  important  point  is  to  obtain  a  satisfactory 
physiological  type.  Only  great  patience  is  capable 
of  producing  this  result  with  certainty.  Speaking 
generally — ^I  might  almost  say,  speaking  literally- 
mechanical  therapy  ought  to  be  proscribed  :  it  haS 
often  led  to  disiaster,  from  not  taking  sufficient  account 
of  resistance  and  of  pain  ;  it  is  too  brutal,  however 
gentle  it  may  be,  and  tries  to  go  too  fast.  Many 
resections  of  the  elbow  have  ended  in  ankylosis  because 
it  has  been  imagined  that  a  new  joint  could  be  pro- 
duced by  a  mechanical  machine. 

8.  Later  Appliances.— Some  patients  after  re- 
covery from  arthrotomy  or  resection  derive  advantage 
from  wearing  a  simple  supporting  .  apparatus  for 
some  months  :  for  the  elbow  or  the  wrist  a  bracelet 
or  gauntlet  of  leather,  for  the  knee  a  laced  spHnt,  for 
the  foot  a  boot  with  lateral  supports.  After  resection 
of  the  knee  a  leather  spHnt  with  rigid  supports  should 


GENERAL  CONSIDERATIONS  33 

be  advised  during  the  first  year  or  two.  After  resection 
of  the  hip  a  raised  boot  is  necessary,  an  orthopaedic 
apparatus  useless. 

9.  Evacuation  of  Patients  with  Wounds  of 
Joints. — ^As  far  as  can  be,  wounds  of  the  joints  should 
be  treated  on  the  spot,  moved  as  little  as  possible 
and  evacuated  as  late  as  can  be  managed.  In  a 
war  of  position  every  joint  wound,  however  small, 
ought  to  be  operated  upon  immediately  after  the 
patient  has  been  brought  in,  for  it  is  only  in  this  way 
that  a  small  wound  can  be  made  to  remain  harmless. 
The  patient's  evacuation  after  operation  should  be 
carried  out  after  complete  immobilisation  has  been 
effected  :  the  apparatus  to  be  preferred  is  a  plaster 
trough.  But  evacuation  ought  not  to  be  ordered,  save 
for  military  necessity,  except  for  convalescents,  that 
is  for  patients  who  have  been  free  from  fever  for  many 
days,  who  have  no  pain,  and  whose  wounds  are 
clinically  aseptic. 


CHAPTER    I    (Continued) 

GENERAL    SURVEY    OF    PRESENT    METHODS 
FOR    OBTAINING    WOUND    ASEPSIS 

The  presentation  of  modern  methods  of  treatment  for 
infected  wounds  meets  with  difficulties  at  this  particu- 
lar time.  Opinions  are  still  divided  concerning"  the 
value  of  certain  new  procedures,  notably  the  Carrel- 
Dakin  treatment  by  multiple  irrigation  of  war  wounds 
with  a  special  antiseptic  fluid ;  a  method  which  has  won 
popular  favor  and  has  been  accepted  by  the  United 
St-ates  Government  for  its  military  medical  services. 
Prominent  German  war  surgeons,  such  as  V.  Bruns 
and  others,  are  equally  convinced  of  its  superiority,  and 
on  the  basis  of  extensive  experience  with  this  treatment 
in  the  worst  type  of  artillery  and  similar  injuries  are 
inclined  to  regard  sodium  hypochlorite  as  the  turning- 
point  in  the  treatment  of  infected  war  wounds  and  the 
hoped-for  solution  of  the  problem  of  chemical  wound- 
disinfection. 

The  status  of  the  treatment  of  war  wounds  as  it  ex- 
isted at  the'  inception  of  the  war  eventuated  in  the 
speedy  revelation  of  the  inadequacy  of  the  procedure 
then  in  use.  The  failure  of  antiseptics  and  asepsis  as 
practised  in  tlie  early  days  of  the  war  has  since  been 
shown  to  be  due,  not  to  a  fallacy  of  the  fundamental 
principle,  but  to  the  Inadequacy  and  incompetence  of 
the  older  technics  and  disinfectants  to  deal  with  the 
new  tj'pe  of  artillery  wounds  and  the  intense  contann'na- 
tion  of  the  soil  of  the  battle  fields  with  a  multiple  of 
anaerobic  germs.  From  the  failure  of  the  old  grow  the 
involution  of  modern  methods  of  wound  treatment.  A 
conflict  arose  between  the  antiseptic  or  Listerian  meth- 
ods, essentially  represented  by  the  Carrel-Dakin  wound 

34 


GENERAL    SURVEY  35 

treatment,  and  the  purel}'^  physiological  method  of  Sir 
Almroth  Wright  and  his  school.  The  gradual  im- 
provement of  the  antiseptic  methods  is  represented  by 
the  evolution  of  the  chlorine  compounds,  with  the  work 
of  Dakin,  Lonain  Smith,  Geo.  Makins,  J.  E.  Sweet, 
and  others.  The  drawbacks  of  the  hypochlorites,  the 
hypochlorous  acid  preparations,  and  the  hypertonic 
salt  solutions  led  to  the  elaboration  of  Dichloramin-T 
and  its  substitutes,  to  the  introduction  of  Flavine  and 
Bipp,  tfc)  Delbet's  method  of  hypoculture  and  his  mag-, 
nesium  chloride,  to  the  use  of  Vincent's  powder,  Hey's 
brilliant  green  paste,  and  a  number  of  other  methods 
of  wound  treatment.  Special  mention  must  be  made 
of  the  new  Serotherapy  introduced  into  wound  treat- 
ment, notably  in  form  of  the  polyvalent  serum  of  Le- 
clorinche  and  Vallee,  the  merits  of  which  are  not  yet 
sufficiently  appreciated,  for  lack  of  familiarity  with  the 
results  accomplished. 

The  success  of  all  modern  methods  of  wound  treat- 
ment is  based  upon  the  fundamental  principle  of  com- 
plete mechanical  or  surgical  sterilization,  the  excision 
of  all  dead  or  dying  tissue,  the  extirpation  of  whole 
wounds  and  bullet-tracts,  which  admits  of  even  imme- 
diate suture  of  war  wounds  in  selected  cases.  It  goes 
without  saying  that  only  the  most  highly  skilled  and 
experienced  surgeons  are  qualified  to  carry  out  the 
primary  closure  of  war  wounds.  Primary  suture  of 
wounds,  as  practised  by  prominent  French  pioneers  in 
this  field,  after  excision  and  during  the  period  of  con- 
tamination, in  other  words,  prophylactic  excision  of  the 
contaminated  wound  tissue,  although  not  yet  generally 
accepted,  is  practically  the  last  word  in  war  sui^gery. 
It  is  this  greater  attention  to  the  niechanical  or  sur- 
gical sterilization  of  wounds  which  has  made  the  strik- 
ing difference  in  the  results  obtained  now  and  at  the 
beginning  of  the  war.  The  success  which  has  lately 
attended  the  treatment  of  infected  war  wounds  on  the 
Western    front,   as    contrasted   with   the   acknowledged 


36  THE    TREATMENT    OF    FRACTURES 

failure  of  surgery  in  the  first  year  of  the  war,  is  un- 
doubtedly due,  not  so  much  to  any  one  of  the  numer- 
ous antiseptics  now  in  vogue,  but  to  the  thoroughness 
with  which  the  contaminated  areas  are  extirpated  sur- 
gically during  the  period  of  contamination,  in  the  first 
teuv  or  twelve,  at  most  fifteen  hours,  before  actual  in- 
fection has  taken  place.  The  extirpation  of  the  dead 
or  hopelessly  damaged  tissue,  before  the  germs  have 
had  time  to  incubate,  is  the  secret  of  success,  and  it  is 
for  this  reason  that  nearly  all  methods  of  chemical 
sterilization  yield  good  results.  Future  investigators 
may  be  expected  to  throw  light  on  the  individual  char- 
acteristics of  the  infecting  bacteria  in  war  wounds, 
and  the  specificity  of  antiseptics  employed  for  the  con- 
trol of  these  infections,  a  line  of  study  suggested  in 
the  Archives  de  Med.  et  de  Pharm.  Militaire  of  1917. 
The  disinfection  of  war  wounds  is  the  easier  the  earlier 
it  is  begun ;  in  other  words,  the  closer  the  treatment 
follows  the  production  of  the  wound.  Surgical  prophy- 
laxis of  infection  is  the  fundamental  feature  of  the 
present  treatment  of  war  wounds,  its  progress,  and 
success. 

The  principles  of  modem  methods  of  wound  treat- 
ment diff*er  so  radically  and  intrinsically  as  hardly  to 
admit  a  classification  of  therapeutic  procedures  now 
in  use  .under  the  heading  of  antiseptic,  physiological, 
vaccine,  and  other  methods.  Any  attempt  at  such 
grouping  would  necessarily  be  open  to  criticism,  as  not 
uncommonly  these  methods  are  combined  or  overlap. 
A  diagnostic-therapeutic  procedure  such  as  Delbet's 
pyoculture  method  requires  a  place  by  itself,  and  this 
is  also  true  to  a  certain  extent  for  a  few  other  curative 
suggestions  which  have  been  offered.  Although  some 
logical  sequence  has  been  aimed  at  in  the  arrangement, 
the  different  methods  are  described  independently,  and 
irrespectively  of  kindred,  competitive,  or  opposite 
ideas  on  the  management  of  infected  wounds.  It  is  not 
the  object   of  this  book  to   extol  any  of  the  curative 


GENERAL    SURVEY  37 

procedures  which  have  been  called  forth  in  abundance 
by  the  wholesale  slaughter  on  European  battle  fields, 
nor  is  it  proposed  to  enter  into  a  discussion  of  the 
value  of  these  methods  from  the  scientific  viewpoint  of 
surgical  pathology.  Without  criticizing  or  grading 
the  various  methods,  the  fact  is  emphasized  that  all  very 
recent  methods  of  wound  treatment  are  of  necessity 
more  or  less  experimental  and  under  trial.  The  text 
aims  at  presenting  in  concise  but  intelligible  form  the 
modern  methods  of  wound  treatment  now  in  use,  so 
that  they  can  be  tried  and  tested  by  those  interested  in 
their  practical  utility. 

The  aseptic  effectiveness  of  the  first  wound  dress- 
ings, as  pointed  out  by  Vincent,  often  governs  the  sur- 
gical prognosis.  After  the  wound  has  been  virtually 
made  clean. and  free  from  necrotic  matter  a  successful 
course  of  repair  and  a  favorable  outcome  are  assisted 
and .  ensured  by  the  purposeful  selection  and  proper 
utilization  of  the  most  advantageous  chemical  agent. 
An  article  is  intended  to  help  the  reader  not  only  in 
this  choice,  but  also  to  provide  him  with  sufficient 
grounds  on  which  to  base  his  own  judgment  as  to  the 
relative  merits  of  modern  methods  of  wound  treatment. 

The  Carrel-Dakin  Method 

The  novelty  of  the  Carrel  method  of  wound  treat- 
ment consists  in  its  providing  a  protracted  and  inti- 
mate contact  between  a  relatively  non-irritant  antisep- 
tic agent  and  the  infected  wound  surface.  In  pursu- 
ance of  this  object  the  same  degree  of  concentration  of 
the  antiseptic  solution  must  be  constaintly  maintained, 
and  this  necessitates  a  special  technic  for  the  constant 
renewal  of  Dakin's  fluid,  which  is  very  unstable  and 
easily  decomposed. 

A  preliminary  requirement  of  this  as  well  as  all 
other  modern  methods  of  wound  treatment  is  the  earliest 
possible  and  scrupulously  careful  cleansing  of  the  in- 


38  THE    TREATMENT    OF   FRACTURES 

fected  wound,  preferably  within  the  first  six  hours, 
with  free  incisions,  removal  of  all  foreign  bodies,  and 
extirpation  of  all  hopelessly  damaged  or  dead  tissues. 
This  surgical  cleansing  of  the  wound  is  followed  by 
the  institution  of  the  Carrel  procedure,  which  has  for 
its  main  object  the  sterilization  of  the  wound  by  chem- 
ical means,  and  aims  at  accomplishing  this  purpose 
through  a  special  mode  of  application  of  a  "definite  an- 
tiseptic solution,  i.e.,  Dakin's  fluid,  claimed  to  be  ap- 
proximately isotonic  with  blood  serum.  The  early 
union  of  the  wound  margins  by  sutures  or  other  means 
which  this  method  renders  practicable  is  the  best  proof 
of  its  efficiency  in  the  treatment  of  infected  war  wounds. 
The  results  of  the  Carrel  method  in  badly  infected 
artillery  and  similar  wounds  are  described  as  far  sur- 
passing those  obtained  by  other  methods.  The  tem- 
perature drops  to  normal  within  48  hours ;  after  a 
week's  treatment,  the  appearance  of  the  wound  surfaces 
is  very  favora,ble;  the  entire  duration  of  the  treatment 
is  considerably  shortened  in  comparison  with  other 
methods.  This  wound  disinfection  guards  against 
lymphangitis  and  lymphadinitis,  as  well  as  against  os- 
teomyelitis in  infected  compound  fractures  ;  amputations 
are  rarely  needed,  in  spite  of  the  gravity  of  the  cases, 
and  deaths  from  sepsis  are  exceptional.  The  cicatrices 
following  the  junction  of  the  disinfected  and  sterilized 
wound  surfaces  resemble  operation  scars  rather  than 
those  obtained  by  the  secondary  suture  of  granulating 
wounds.  This  outcome  constitutes  a  valuable  auxiliary 
in  the  mechanical  after-treatment  of  war  wounds. 

A  special  committee  appointed  by  the  Director-Gen- 
eral of  the  British  Array  Medical  Services  for  the  pur- 
pose of  investigating  and  reporting  on  the  Carrel- 
Dakin  treatment  of  wounds  is  of  the  opinion  that  this 
method  of  treatment,  if  carried  out  thoroughly,  is  full 
of  promise,  and  believes  that  it  will  (1)  diminish  the 
dangers  incidental  to  sepsis,  including  secondary  hem- 
orrhage;   (2)   hasten  the  patient's   convalescence;    (3) 


GENERAL    SURVEY  39 

lessen  the  liability  to  stiff  joints  and  cicatrical  deformi- 
ties ;  (4)  enable  the  patients  to  leave  the  hospital  with 
better  general  health  than  they  otherwise  niiglit ;  and 
that  (5)  when  secondarj-^  operations  become  necessary 
these  operations  are  more  likel}'  to  be  free  from  septic 
complications  than  when  some  other  system  of  primary 
treatment  has  been  adopted.  (Brit.  ]Med.  Jrl.,  II,  1917. 
p.  597.)  In  conformity  with  these  views,  the  Britisli 
Army  Medical  Department  has  arranged  that  the  treat- 
ment can  be  continuously  carried  out  not  only  in  the 
Front  and  Base  Hospitals  but  also  in  ambulance  trains, 
hospital  ships,  and  the  hospitals  in  Great  Britain.  (Sir 
Anthony  Bowlby.) 

The  method  takes  its  name  from  the  tcchnic  spe- 
cially devised  by  Alexis  Carrel  for  bringing  Dakin's 
fluid  of  sodium  hypochlorite  into  contact  witli  tlie  in- 
terior of  infected  wounds.  Dakin's  solution  in  a  septic 
wound  acts  both  as  an  antiseptic  and  as  a  cleansing 
agent  or  remover  of  dead  tissue  liable  to  serve  as  a 
nidus  for  microorganisms.  Although  it  sliglitly  irri- 
tates the  skin,  this  disinfecting  fluid  does  not  injure  liv- 
ing tissue,  and  it  is  described  by  Dr.  Lyle  as  an  ideal 
isotonic  wound  antiseptic  of  high  bactericidal  and  low 
toxic  or  irritating  quality.  The  solution  possesses 
hemolytic  properties  and  will  dissolve  recent  bloodclots ; 
so  that  a  good  hemostasis  is  essential  to  guard  against 
the  dangers  of  secondary  hemorrhage. 

In  order  to  combine  the  strongest  germicidal  with 
the  lowest  irritating  action,  the  solution  must  be  of 
definite  strength,  namely,  between  0.45  and  0.50  per 
cent.  The  fluid  is  deprived  of  its  chlorin  in  an  hour  or 
less  by  the  w^ound  secretions,  which  render  it  inert.  The 
many  details  of  the!  necessary  technic  require  the  atten- 
tion of  a  large,  weJl-trained  staff  of  doctors  and  nurses, 
so  that  the  method  is  hardly  applicable  outside  of  a 
thoroughly  equipped  modern  hospital.  Several  modifica- 
tions and  simplified  apparatus  have  been  suggested  and 
will  receive  consideration  in  the  text. 


40  THE    TREATMENT    OF    FBACTURES 

Dakin's  fluid  is  used  in  a  solution  of  0.5  per  cent, 
strength,  and  is  prepared  according  to  two  formulas, 
with  and  without  the  addition  of  boric  acid.  Practical 
experience  with  the  two  solutions  apparently  favors  the 
boric  acid  free  fluid.  The  following  formulas  for  the 
preparation  of  the  two  fluids  were  given  by  Dr.  Dakin. 

Dakin  Solution  Without  Boric  Acid 

"Neutral  hypochlorite  prepared  without  boric  acid 
is  best  made  according  to  the  formula 'given  by  Dau- 
fresne,  and  at  the  present  time  is  perhaps  more  gener- 
ally used  than  any  of  the  other  modifications.  Two 
hundred  grams  of  good  bleaching  powder  are  put  in  a 
12-liter  bottle  with  five  liters  of  tap-water.  The  solu- 
tion is  shaken  vigorously  and  allowed  to  stand  for  at 
least  six  hours,  unless  a  mechanical  shaker  is  used, 
when  half  an  hour's  shaking  will  be  found  sufficient.  In 
another  vessel,  100  grams  of  dry  sodium  carbonate  and 
80  grams  of  sodium  bicarbonate  are  dissolved  in  five 
liters  of  cold  water  and  then  added  to  the  bleaching 
powder  mixture.  The  whole  is  shaken  vigorously  for 
a  few  minutes,  and  the  precipitate  allowed  to  settle.  At 
the  end  of  half  an  hour  the  clear  solution  is  siphoned 
out  and  then  filtered  through  paper.  The  proportions 
given  above  for  the  carbonate  and  bicarbonate  of 
soda  are  those  given  by  Daufresne.  It  is  our  experi- 
ence, however,  that  with'  most  brands  of  American 
bleaching  powder  it  is  better  td  use  90  grams  of  each 
salt.  This  solution  must  invariably  be  tested  for  neu- 
trality by  adding  a  pinch  of  solid  phenolphthalein  to 
a  little  of  the  solution.  If  the  solution  should  react 
alkaline,  one  of  three  methods  must  be  employed  to 
correct  it,  otherv/ise  skin  irritation  will  surely  result. 

"(a)  Pass  carbon  dioxid  gas  into  the  solution  until  a 
sample  shows  no  alkalinity  when  tested  as  described. 
This  is  perhaps  the  best  method. 

"'(?))    A  neutral  hypochlorite  may  be  secured  by  re- 


GENERAL    SURVEY  41 

diicing  the  proportion  of  carbonate  of  soda  and  Increas- 
ing- the  bicarbonate. 

"(c)  Boric  acid  may  be  added  until  neutrality  Is 
secured.  An  advantage  of  the  carbonate  preparation 
Is  that  It  possesses  greater  stability  and  can  be  kept  for 
several  weeks  without  much  cfeterloratlon.  On  the.  other 
hand,  with  varying  qualities  of  bleaching  powder,  con- 
taining different  amounts  of  free  lime,  it  is  more  diffi- 
cult to  adjust  the  proportions  so  as  to  obtain  a  neu- 
tral solution  directly.  Probably  those  having  adequate 
laboratory  facilities  will  prefer  the  carbonate-bicar- 
bonate solution,  while  the  mixture  containing  boric  acid 
is  readily  made  under  less  favorable  circumstances." 

Dakin  Solution  with  Boric  Acid 

"Neutral  hypochlorite  prepared  with  boric  acid  Is 
best  made  as  follows :  One  hundred  and  forty  grams  of 
dry  sodium  carbonate  (NaCO),  or  four  hundred  grams 
of  the  crystallized  salt  (washing  soda)  are  dissolved 
in  twelve  liters  of  tap-water,  and  two  hundred  grams 
of  chloride  of  lime  (chlorinated  lime)  of  good  quality 
are  added.  The  mixture  is  well  shaken,  and  after  half 
an  hour  the  clear  liquid  Is'  siphoned  off  from  the  pre- 
cipitate of  calcium  carbonate  and  filtered  through  a 
plug  of  cotton ;  forty  grams  of  boric  acid  are  added  to 
the  clear  filtrate,  and  the  resulting  solution  is  ready 
for  use.  A  slight  additional  precipitate  of  calcium 
salts  may  slowly  occur,  but  it  is  of  no  significance.  The 
solution  should  not  be  kept  longer  than  one  week.  The 
boric  acid  must  not  be  added  to  the  mixture  before 
filtering,  but  afterward.  The  solution  should  be  tested 
by  adding  some  of  It  to  a  pinch  of  solid  phenolphthal- 
ein.  If  a  red  color.  Indicating  free  alkali,  shouW  de- 
velop, a  little  more  boric  acid  must  be  added  In  order 
to  remove  It," 

No  caustic  alkali  must  exist  In  sodium  hypochlorite 
solutions  destined  for  surgical  use. 


42  THE    TREATMENT    OF   FRACTURES 

A  very  simple  and  practical  test  for  alkalinity  is 
recommended  by  Dr.  H.  H;  M.  Lyle  : 

Pour  20  c.c.  of  the  solution  into  a  glass,  and  drop  on 
the  surface  of  the  liquid  a  few  centigrams  of  powdered 
phenolphthalein.  Agitate  the  fluid  by  giving  the  glass 
a  circular  motion,  as  if  one  were  rinsing  the  glass.  The 
liquid  ought  to  remain  colorless.  A  red  tint  more  or 
less  intense  indicates  the  presence  of  a  quantity  of  free 
alkali,  or  an  incomplete  carbonation  due  to  faults  of 
the  technic. 

Titration  of  the  Solution  (Lyle) 

"Measure  10  c.c  of  the  solution,  add  20  c.c.  of  1  :J0 
iodin  solution  and  20  c.c.  of  acetic  acid.  Pour  into 
this  mixture  a  decinormal  solution  (2.48  per  cent.)  of 
sodium  thiosulphate  (hyposulphite)  until  decoloration. 
Let  N  equal  the  number  of  cubic  centimeters  of  thiosul- 
phate employed.  Then  the  quantity  of  sodium  hypo- 
chlorite for  100  c.c.  of  the  solution  would  be  given  by 
the  equation : 

T  —  N  X  0.03725. 

"Precautions :  Never  heat  the  solution.  If,  in  case  of 
an  emergency,  it  is  necessary  to  titrate  the  chlorinated 
lime,  use  only  water,  never  with  the  solution  of  soda 
salts. 

^'^Do  not  use  old  solutions.  Hypochlorite  solutions 
change  quality  in  the  light,  more  slowly  in  the  dark,  but 
will  not  keep  indefinitely  under  any  conditions.  For 
practical  purposes,  sodium  hypoclilorite,  when  properly 
kept  in  a  dark  place,  docs  not  lose  in  strength  as  re- 
gards its  effectiveness  (the  deterioration  not  exceeding 
0.505  to  0.500  in  three  weeks)." 

Equipment 

(1)  A  sodium  hypochlorite  solution  of  0.5  per  cent, 
strength,  prepared  according  to  the  technic  described 
above. 


GENERAL   SURVEY 


43 


(2)  A  glass  receptacle  holding  from  500  to  1000  c.c. 

(3)  Ordinary     medium-sized     rubber     tubing,     two 
yards. 

(4)  A  movable  clamp  for  the  regulation  of  the  flow 
through  the  main  distributing  tube. 


Fig.  la. — Glass  Connection  Tubes,  Vision  Tubes  and  Stop-cocks. 

(5)  Rubber  instillation  tubes  of  assorted  widths 
(average  size  No.  16  French)  and  about  25  cm.  in 
length.     The  ends  are  tied,  and  a  number  of  very  small 


44     THE    TREATMENT    OF   FRACTURES 

holes  are  then  punched  out  of  the  tubes ;  these  holes 
are  no  larger  than  1  mm,  or  1/25  of  an  inch  in  diam- 
eter.    The  internal  diameter  of  the  primary  and  second- 


Fig.  2a. — Carrel's  Distributing  Tubes. 

ary  tubes  is  7  mm.  and  that  of  the  final  distributing 
tubes  is  4  mm. 

(6)  Ordinary   rubber  drainage   tubes,  without   per- 
forations, 25.35  cm.  in  length. 

(7)  Glass  tubes  for  connection  and  distribution. 


GENERAL    SURVEY  45 

(8)  Cotton  surrounded  by  gauze,  for  dressings  of 
different  sizes,  (1)  fitting  well  around  the  leg;  (2)  fit- 
ting well  around  the  arm;  (3)  a  small  size.  The  thick- 
ness of  these  dressings  is  about  3  cm. ;  they  consist  of 
a  layer  of  absorbent  cotton  and  a  thicker  layer  of  non- 
absorbent  cotton.  The  dressing  is  held  by  straps  of 
webbing,  with  adjustable  buckles. 

(9)  Sterilized  gauze  squares  soaked  in  yellow  vase- 
lin  (petrolatum)  serve  for  the  protection  of  the  skin. 
White  vaselin  must  not  be  used. 


Employment  of  Hypochlorite  Solutions 

(1)  Preparation  of  the  Wound. — The  first  sur- 
gical intervention — which  should  be  as  prompt,  thor- 
ough, and  aseptic  as  possible — comprises  a  routine  me- 
chanical wound  disinfection,  with  removal  of  all  foreign 
bodies,  fragments  of  projectiles,  shreds  of  clothing,  and 
so  forth.  The  following  rules  have  been  laid  down  on 
the  basis  of  practical  experience:  Paint  the  part  with 
iodine  tincture,  and  trim  away  the  necrotic  skin  edges 
of  the  wound  with  a  sharp  knife.  Lay  the  wound  open, 
using  clean  instruments,  and  remove  all  that  does  not 
belong  there  or  that  may  have  been  infected,  giving 
special  attention  to  all  pouches  and  wound  recesses,  as 
possible  lurking-places  of  a  latent  infection.  Be  gentle 
and  conservative,  sparing  all  non-infected  tissues  and 
all  those  reasonably  safe  from  infection. 

Save  all  that  can  possibly  be  saved  of  comminuted 
bone-fragments. 

The  patch  taken  by  the  projectile  must  be  carefully 
resected  and  the  exposed  muscular  surfaces  be  freed 
from  adherent  dirt  and  other  contamination.  Bone 
wounds  require  the  same  accurate  mechanical  cleaning 
as  soft  parts  wounds.  Finally,  the  wound  must  be 
carefully  examined  from  the  standpoint  of  a  reliable 
hemostasis.  Not  only  is  it  difficult  to  disinfect  blood- 
infiltrated  muscle  tissues,   but   recently   formed   blood- 


46  TEE    TREATMENT    OF   FRACTURES 

clots  are  liable  to  be  dissolved  by  hypochlorite  solu- 
tions, involving  the  danger  of  secondary  hemorrhage. 

The  object  of  the  hypochlorite  technic  is  to  keep  the 
disinfecting  liquid  in  constant  contact  with  all  the  sur- 
faces of  the  wound.  Counter-openings  for  dressings  are 
only  exceptionally  applied,  and  when  needed  must  not 
be  placed  at  the  most  dependent  point. 

(2)  Introdltction  of  the  Instillation  Tubes. — 
The  nature  of  the  wound  governs  the  placing  of  the 
tubes,  which  must  be  put  so  as  to  bring  the  disinfecting 
fluid  into  direct  contact  with  every  portion  of  the 
wound.  The  technic  varies  according  to  the  super- 
ficial, penetrating,  or  perforating  character  of  the 
lesion. 

{a)  Surface  Wounds, — These  wounds  are  covered 
with  a  thin  layer  of  gauze,  on  which  lie  the  instillation 
tubes,  in  a  number  adapted  to  the  needs  of  a  given  case. 
Rubber  cufFs  and  sutures  retain  the  tubes  at  the  wound 


Fig.  3a. — Showing  the  mode  in  which  the  small  distributing 
tubes  are  carried  through  the  dressing  to  the  various  parts  of 
the  wound  (Carrel  and  Dehelly). 


margins.  A  two-way  flax  tube  is  sometimes  used.  The 
placing  of  the  tubes  directly  on  the  surface,  without 
the  intervening  layer  of  gauze,  would  result  in  clogging 


GENERAL    SURVEY  47 

and  blocking  of  the  orifices  by  granulations.  Access 
of  the  germicidal  solution  to  all  parts  of  the  wound 
would  be  hindered  by  thick  gauze  layers  stiffened  with 
the  secretions  of  the  wound. 

{h)  Penetrating  Wounds. — One  readily  understands 
how  a  rubber  tube  without  openings  in  its  walls  is 
passed  down  nearly  to  but  without  reaching  the  floor 
of  a  simple  wound  cavity,  with  the  result  that  the  dis- 
infecting liquid  wells  up  from  the  bottom.  The  ragged 
walls  of  Avound  cavities  at  the  end  of  wide  channels 
must  be  held  up  by  means  of  a  little  gauze,  so  as  to 
facilitate  the  universal  spreading  of  the  bactericide. 
Perforated  tubes  wrapped  in  toweling  (see  Fig.  2a) 
are  used  for  penetrating  wounds  with  a  low  dependent 
point  of  entrance  (posterior  surface  of  legs  and  arms, 
back,  and  buttocks),  but  non-perforated  tubes  may  be 
employed,  the  essential  point  being  the  continued  con- 
tact of  the  disinfecting  agent  with  the  wound. 

(c)  Perforating  Wounds. — Infection  of  such  wounds 
is  controlled  by  passing  a  perforated  tube,  tied  at  its 
end,  from  the  lower  to  the  higher  wound.  The  dis- 
infecting liquid  is  distributed  over  the  entire  wound 
as  it  flows  from  the  small  openings  in  the  tube  and  re- 
turns to  the  lower  orifice  along  the  wound  channel. 

A  hypochlorite  bath  of  ten  to  fifteen  minutes  is  the 
treatment  for  open  amputation  stumps  and  for  periph- 
eral wounds  of  the  extremities,  to  be  repeated  every 
two  hours  until  the  wound  is  sterilized.  Cutaneous  irri- 
tation with  the  soda  hypochlorite  is  guarded  against 
by  smearing  the  skin  with  sterile  yellow  vaselin. 

Technicat.  Precautions. — In  order  to  secure  suffi- 
cient penetration  of  the  disinfecting  fluid,  it  is  impera- 
tive to  guard  against  certain  sources  of  error,  as 
follows:  (1)  Slipping  or  dropping  of  one  of  the  con- 
ducting tubes,  (2)  Blocking  of  one  or  more  tubes  by 
bloodclot.  (3)  Kinks  and  bends  in  imperfectly  placed 
tubes.  (4)  Neglected  wound  recesses,  not  reached  by 
any  tube. 


48  THE    TREATMENT    OF    FRACTURES 


The  irrigation  apparatus  is  sometimes  incorrectly 
installed,  a  common  fault  being  that  a  drop-counting 
appliance  is  connected  with  a  number  of  tubes ;  here  the 


Fig.  4a. — Showing  Carrel  method  of  irrigating  wound  with 
the  Dakin  Fluid.  Note  on  the  main  distributing  tube  the  pinch- 
cock  below  the  reservoir.  The  wound  is  covered  witt^  the 
dressing,  which  is  fastened  by  safety-pins.  The  distributing 
tube  is  similarly  held  in  place  by  being  pinned  to  the  plaster  bast 
(Carrel  and  Dehelly  modified). 


GENERAL   SURVEY 


49 


fluid  may  flow  down  one  tube  to  the  exclusion  of  the 
others,  in  conformity  with  the  laws  of  gravity.  A  very 
narrow  main  tube,  or  a  very  small  inferior  outlet  of  the 
reservoir,  will  reduce  the  flow,  so  that  the  bactericidal 
fluid  does  not  pass  along  as  many  tubes  as  it  should  in 
order  to  disinfect  the  entire  wound.  Rules  concerning 
the  relative  calibers  of  the  several  tubes  and  the  installa- 
tion of  the  irrigation  apparatus  must  be  strictly  fol- 
lowed. 

An  insufficient  delivery  of  disinfecting  fluid  is  a  more 
serious  error  than  an  excessive  amount,  which  is  trouble- 
some to  the  patient,  but  will  not  harm  the  wound  itself, 
as  will  an  inadequate  supply  of  hypochlorite.  This  is 
indicated  by  the  presence  of  unmodified  secretions  in  the 
wound  and  an  offensive  odor  of  the  pus. 


Fig.  5a. — Nurse  using  a  pinch-cock  and  so  instilling 
antiseptic  liquid. 


50  THE    TREATMENT    OF    FRACTURES 

Pain  is  caused  by  excessive  pressure  of  liquid  in  the 
wound,  which  is  sometimes  due  to  a  very  small  incision 
retarding  the  back  flow  of  the  fluid  between  the  walls  of 
the  wound  and  the  conducting  tube.  Another  easily 
remedied  occasional  cause  of  excessive  pressure  is  the 
exaggerated  elevation  of  the  reservoir  above  the  level  of 
the  bed. 

The  Healing  Wound. — Only  sterilized  instruments, 
never  the  gloved  hands,  are  allowed  to  touch  the  wound 
or  the  dressings.  Once  in  two  hours,  or  twelve  times  in 
the  twenty-four  hours,  the  disinfecting  fluid,  usually  to 
an  amount  of  10  c.c,  and  at  a  rate  of  flow  of  from 
five  to  twenty  drops  per  minute,  is  passed  into  the 
wound.  This  is  accomplished  by  releasing  for  a  few 
seconds  the  pinch-cock  which  regulates  the  flow,  and 
requires  the  attention  of  a  nurse.  The  instillations  are 
continued  until  sterility  has  been  obtained,  as  shown  by 
the  routine  bacteriological  control.  The  instillation 
tubes  are  then  replaced  by  a  compress  soaked  in  the 
hypochlorite  solution.  The  progress  of  the  wound  and 
the  condition  of  the  irrigation  apparatus  are  ascertained 
by  frequent  inspection,  at  least  once  daily. 

Bacteriologic  Controt.  of  the  Wound. — Deter- 
mining the  number  of  bacteria  on  the  wound  surface 
is  an  integral  item  in  the  Dakin-Carrel  method.  The 
diminishing  quantity  of  germs  is  the  indicator  of  ad- 
vancing sterilization.  The  progress  of  the  wound  is 
ascertained  by  means  of  "smear  specimens,"  which  are 
easily  interpreted  by  those  having  even  an  elementary 
knowledge  of  bacteriology.  Cultures  are  less  desirable 
for  this  particular  purpose,  the  object  being  to  find  out 
what  the  wound  actually  contains  rather  than  what 
growths  might  be  obtained  in  the  incubator.  No  smears 
can  be  prepared  from  a  bleeding  wound,  as  the  blood 
will  effectually  conceal  the  bacteria. 

Technique. — A  stiff  platinum  wire,  mounted  on  a  glass 
rod,  serves  for  the  removal  of  the  specimen  from  the 
wound.      The   standard   loop   in   use   in   bacteriological 


GENERAL    SURVEY  51 

laboratories  answers  the  requirements.  The  material 
must  be  taken  at  the  end  of  the  two  hours'  interval  be- 
tween treatments,  and  from  the  deeper  regions  most 
likely  to  be  contaminated,  such  as  jagged  wound  re- 
cesses, damaged  bony  surfaces,  necrotic  fascia,  etc.  The 
loop  transfers  the  material  to  microscopic  slides,  witli 
identification  labels.  The  slides  are  then  taken  to  the 
laboratory,  where  they  are  fixed  and  stained. 

Fixation  and  staining  of  specimen. — Pass  the  slide, 
smear  towards  flame,  three  times  through  the  flame  of 
a  Bunsen  burner.  Next,  place  it  on  a  glass  support 
and  cover  with  a  few  drops  of  carbolized  thiolin.  Let 
the  stain  act  for  half  a  minute,  then  wash  with  water, 
and  put  aside  to  dry. 

Counting  of  Bacteria. — Place  a  drop  of  cedar  oil  on 
each  slide,  and  count  the  number  of  germs  in  a  micro- 
scopic field  with  a  No.  12  immersion  objective  and  a 
No.  3  eye  piece.  It  is  advisable  to  examine  several 
fields,  especially  near  the  end  of  the  treatment,  before 
a  wound  is  closed.  Only  a  rough  estimate  of  the  num- 
ber of  germs  in  a  microscopic  field  is  required,  the  ob- 
ject being  to  ascertain  the  progress  of  the  treatment. 
The  control  is  made  every  day,  and  the  findings  are 
noted  on  a  chart.  Absence  of  germs  indicate  a  sterile 
wound,  which  may  be  closed  by  sutures.  Not  less  than 
three  successive  sterile  counts  should  be  relied  on. 

After  the  hypochlorite  treatment  is  stopped,  a  steril- 
ized wound  may  be  re-infected  by  way  of  the  epithelial 
margins  and  the  adjacent  skin.  To  guard  against  this 
re-infection,  it  is  recommended  to  wash  the  entire  sur- 
roundings with  neutral  oleate  of  soda. 

The  hypochlorite  treatment  sterilizes  soft  parts 
wounds  in  five  to  nine  days,  as  a  rule.  Contused 
wounds  with  extensive  tissue  destruction  need  a  more 
prolonged  contact  with  the  disinfecting  fluid.  From 
two  to  four  Aveeks  are  required  for  the  sterilization  of 
fractures ;  all  bone  sequestra  must  be  removed.  Germs 
persist    the    longest    on    the    skin    and    bony    surfaces. 


52  THE    TREATMENT    OF   FRACTURES 

Microorganisms  without  distinction  of  species  are  de- 
stroyed by  hypochlorite;  but  although  the  free  ana- 
tomical   elements    are    equally    affected,    the    defensive 


Fig.  6a. — Case  577.     Wound  of  knee,  5th  day 


phagocytosis,  according  to  Carrel  and  Dehelly,  is  not 
disturbed  in  the  deeper  regions  unreached  by  the  so- 
lution. 

Closure  of  Wound. — A  wound  shown  to  be  sterile  by 
three  successive  bacteriological  tests  is  ready  for  clos- 
ure ;  usually  after  a  week  to  nine  daj^s,  on  the  fifth  day 
in  favorable  cases.  Layer  sutures  are  the  preferred 
mode  of  closure.  When  the  suture  method  is  not  ap- 
plicable, elastic  adhesive  straps  are  used  to  draw  the 
wound  edges  together.  The  straps  must  be  long  enough 
to  be  passed  around  the  entire  circumference  of  the 
limb,  guarding  against  too  tight  a  compression  by  a 
circular  bandage. 

Elastic  traction  is  utilized  to  overcome  an  extensive 
loss  of  substance,  which  prevents  the  apposition  of  the 
wound  margins.  Strips  of  adhesive  plaster  about  three 
inches  in  width  and  four  inches  longer  than  the  wound 
are  punched  on  one  edge  and  shoc-liooks  arc  inserted 
at  intervals  of  two  cm.  Two  such  strips  arc  attached 
to  the  skin  parallel  with  and  on  each  side  of  the  wound. 


GENERAL    SURVEY 


53 


Strong  rubber  laces  are  passed  over  opposite  hooks, 
and  by  virtue  of  their  elasticity  progressively  bring  the 
wound  margins  •together.      The  hooks  can   also   be  in- 


Fig.  7a. — Case  577.    Suture,  14th  day 


serted  into  the  hemmed  edges  of  two  canton  flannel 
bands,  slightly  longer  than  the  wound,  and  a  trifle 
narrower  than  half  the  circumference  of  the  limb.  The 
woolly  side  of  the  flannel  is  placed  on  the  skin,  which 
has  first  been  painted  with  resin  varnish,  or  Heusner's 
glue,  up  to  the  edges  of  the  wound.  The  rubber  lacing 
is  carried  out  as  with  the  strips  of  <adhesive  plaster. 

Operative  Technique  of  Carrel-Dakiris-Daufresne 
Treatment. — (According  to  Captain  R.  M.  Row.e,  of  the 
British  Expeditionary  Force:  "Whenever  possible,  the 
wound  should  be  converted  into  a  broad-based  crater 
and  all  damaged  tissue  detritus  and  free  fragments  of 
bones  removed.  Hemostasis  is  most  important,  by  liga- 
ture, pressure  and  hot  water.  It  is  a  faulty  technic  to 
introduce  the  irrigation  tubes  into  an  oozing  wound. 
The  tubes  must  be  inserted  first  into  the  depths  and 
recesses,  then  more  superficially.  The  tubes  are  made 
stable  by  fragments  of  one-inch  web  bandage  removed 
from  Dakin-Daufresne  solution  and  arranged  lightly 
in  contact  with  the  distal  extremities  of  the  irrigation 


54  THE    TREATMENT    OF   FRACTURES 

tubes.  The  irrigation  tubes  (4  mm.  calibre  and  30  cm. 
long)  are  tied  at  the  distal  end  with  linen  thread.  Per- 
forations extend  from  this  point  for  5  cm.,  10  cm.  or 
15  cm.  along  the  length  of  the  tube,  so  as  to  vary  with 
the  dimensions  of  the  wound  treated."  (Brit.  Med. 
Jrl.,  II,  1917,  p.  389.) 

In  order  to  obviate  the  necessity  for  a  trained  hos- 
pital staff,  as  required  by  the  Carrel  method,  several 
types  of  simplified  irrigation  apparatus  have  been  de- 
vised, which  aim  at  carrying  into  the  wound,  at  stated 
intervals,  an  amount  of  liquid  which  can  be  arbitrarily 
regulated. 

The  following  change  in  the  Carrel  method  of  irri- 
gating wounds  is  suggested  by  Kellock  (Lancet,  II, 
1917,  p.  348),  who  found  it  of  much  service:  "Taking 
a  piece  of  drainage  tube  about  8  or  10  inches  in  length 
and  of  calibre  about  equal  to  that  of'  a  No.  8  catheter, 
the  end  is  securely  closed  by  a  ligature  and  a  small 
oblique  incision  made  with  a  sharp  scissors  as  near  as 
possible  to  the  closed  end.  The  incision  should  cut  a 
small  valve,  with  apex  directed  towards  the  closed  end 
— the  mare  oblique  it  is  the  better — and  should  at  its 
base  divide  one-third  of  the  circumference  of  the  tube. 
This  incision  will  be  found  to  act  as  a  most  efficient 
valve,  opening  under  very  slight  pressure  from  within, 
and  preventing  any  regurgitation  of  pus  or  of  the  irri- 
gated fluid.  The  tied  end  should  be  inserted  to  the 
very  depth  of  the  wound  and  the  free  end  left  project- 
ing through  the  dressing;  the  number  of  tubes  used 
must  depend  on  the  size  and  character  of  the  wound, 
but  it  will  generally  be  found  that  one,  or  at  the  most 
two,  will  suffice. 

"In  case  of  a  perforating  wound  of  a  limb  or  of  a 
M^ound  with  two  openings  widely  separated,  a  very  use- 
ful modification  is  to  ligature  the  tube  at  its  centre  and 
cut  a  valve  on  each  side  of  the  ligature  and  pointing 
towards  it.  This  is  passed  through  the  wound  and 
the  irrigation  done  from  the  ends.      In  this  way  any 


GENERAL    SURVEY  55 

fluid  that  is  irrigated  into  the  free  ends  of  tlie  tube 
must  certainly  find  its  way  to  tlie  very  bottom  of  the 
wound  and  from  there  towards  the  surface. 

To  secure  the  tubes  in  position,  a  useful  plan  is  to 
make  a  small  independent  incision  through  the  skin 
near  the  edge  of  the  wound  just  large  enough  to  grip 
tlie  tube  without  occluding  its  lumen,  and  the  free  end 
of  the  tube  is  drawn  through  this  after  the  tied  end 
has  been  passed  to  the  bottom  of  the  wound.  The  free 
ends  of  the  tube  are  left  outside  the  dressing  and  the 
irrigating  fluid  passed  into  them  by  means  of  a  glass 
syringe.  Gravity  alone  will  generally  suflice ;  if  neces- 
sary, a  little  assistance  may  be  given  by  using  the 
plunger  of  the  syringe." 

For  deep  and  inaccessible  wounds,  notably  com- 
pound fractures  of  the  femur,  W.  H.  Taylor  and  N.  B. 
Taylor  (Brit.  Med.  Jrl.,  II,  1917,  p.  453)  recommend 
the  use  of  a  device  which  insures,  even  more  consistently 
tlian  the  Carrel  method  itself,  the  direct  and  prolonged 
exposure  of  every  part  of  the  wound  to  a  disinfecting 
solution  whose  concentration  remains  constant.  The}-^ 
consider  a  reliable  system  of  liquid  right  closure  as  es- 
sential in  wound  treatment,  on  the  basis  of  the  reflection 
that  the  resulting  alternate  tension  and  collapse  in  the 
wound  are  necessary  to  the  deeper  penetration  of  the 
disinfecting  fluid  and  tlie  production  of  automatic 
cleansing  or  "tidnl"  movements. 

Description  of  Device. — A  rubber  bag,  after  the  pat- 
tern of  an  ice  bag,  is  used,  and  a  soft  rubber  collar  is 
formed  in  the  center  of  the  "top-sheet"  T.  A  suction 
ring,  S,  is  attache/!  to  the  circumference  of  the  top- 
sheet.  Round  the  under  surface  of  S  a  gutter  is  formed, 
the  sharp  rubber  lips  on  either  side  of  which  are  de- 
signed to  grip  the  skin.  A  small  tube,  K,  leads  from 
the  gutter  to  the  space  beneath  the  collar.  A  valve  on 
this  tube  lets  air  pass  from  the  gutter  and  holds  the 
suction  by  blocking  its  return.  The  drainage  tube  from 
the  wound  connects  with  a  cannula  in  the  collar,  whose 


56  THE    TREATMENT    OF    FRACTURES 

outer  end  connects  with  a  common  tube.  This  common 
tube  divides  into  an  inflow  and  outflow  a  few  inches 
from  the  collar  by  means  of  a  Y-piece.  There  is  a  clip 
on  the  inflow,  and  another  clip  on  the  outflow. 

To  apply,  first  paint  the  skin  with  a  mixture  of 
petrolatum,  Canada  balsam,  and  rubber  dissolved  in 
ether.  These  ingredients  in  equal  parts  make  a  soft 
elastic  paste  that  is  not  too  sticky.  The  device  is  laid 
on  so  that  the  suction  ring  rests  on  sound  skin,  with 
the  wound  more  or  less  in  the  center.  The  washer,  of 
plastic  felt,  is  now  moulded  to  the  suction  and  pressed 
down  all  around  until  the  rubber  lips  make  contact 
everwhere  with  the  skin.  When  the  felt  has  hardened 
a  little  cotton  may  be  tucked  between  it  and  the  ring 
wherever  contact  of  the  lips  is  not  perfect.  The  ring 
is  very  flexible,  and  its  attenuated  lips  can  easily  be 
made  to  conform  to  an  irregular  surface.  When  the 
bandage  is  applied  over  all,  the  air  which  is  thereby 
expressed  from  the  gutter  through  the  small  tube  can- 
not return  on  account  of  the  valve.  After  connecting 
the  drainage  tube  to  the  cannula  the  collar  is  closed. 

To  flood  the  wound,  close  the  outflow,  when  the  fluid 
overflows  and  extravasates  into  the  space  between  the 
top-sheet  and  the  top  of  the  suction  ring.  Here  the 
pressure  operates  to  force  the  suction  ring  against  the 
skin ;  additional  to  suction  beneath  the  ring,  which  is 
still  maintained  by  the  valve. 

To  suck  the  wound  out,  close  the  inflow  tube  and 
open  the  outflow,  when  siphonage  aspirates  the  wound, 
collapses  the  collar,  and  renews  the  negative  pressure 
beneath  the  suction  ring  through  the  tube. 

If  the  wound  is  a  through-and-through  one,  a  simi- 
lar device,  with  its  tube,  but  unprovided  with  a  col- 
lar, is  applied  to  the  lower  opening.  Its  suction  ring  is 
influenced,  too,  by  a  negative  pressure  in  the  wound. 

A  suction  apparatus  to  surmount  difficulty  of  drain- 
age, to  be  used  with  Carrel's  irrigation  tubes,  was  re- 
cently suggested  by  George  C.  Sneyd,  for  wounds  of  a 


GENERAL    SURVEY  57 

cavernous  type  where  a  large  retentive  septic  space  is 
present  and  where  counter-drainage  is  anatomically  im- 
possible. The  suction  tube  has  no  sharp  edge  and  bears 
a  lateral  hole  one-quarter  inch  distant  from  its  termina- 
tion, which  hole  lies  on  the  bottom  of  the  wound.  The 
wound  is  covered  by  a  single  layer  of  sterile  gauze.  The 
patient  himself  can  attend  to  the  apparatus.  A  clip  on 
the  suction  tube  allows  the  wound  to  remain  filled  with 
the  disinfecting  fluid  for  any  desirable  period. 

As  a  simplification  of  the  Carrel-Dakin  treatment  of 
wounds,  Dimond  and  McQueen  devised  for  individual 
separate  cases  a  narrow-necked  bottle  to  replace  the 
ampules  and  apparatus  recommended  by  Carrel  in  his 
book.  For  the  treatment  of  a  large  number  of  pa- 
tients, they  devised  a  system  of  siphonage  with  auto- 
matic flushing  and  refilling,  so  that  once  started  no  at- 
tention is  required.  This  method  requires  only  that  the 
reservoir  should  be  kept  supplied  with  fluid.  The  auto- 
matic flushing  from  each  of  the  two  bottles,  neither  of 
which  need  be  of  a  greater  capacity  than  four  ounces, 
does  not  require  any  further  supervision.  (For  detailed 
description  and  illustrations,  interested  readers  are  re- 
ferred to  the  Brit.  Med.  Jrl.,  II,  1917,  p.  387). 

Modification  of  Carrel  Apparatus. — Rolland  (La 
Presse  Medicale,  No.  59,  1917,  p.  627)  recommends  a 
simple  and  inexpensive  contrivance,  by  means  of  which 
efficient  wound  irrigaition  according  to  Carrel  can  be 
accomplished  with  the  ordinary  hospital  equipments,  at 
a  minimum  outlay.  The  apparatus  consists  essentially 
of  a  graduated  flask,  with  an  opening  of  60  cm.,  which 
admits  a  rubber  stopper,  pierced  by  three  holes,  through 
which  pass  three  glass  tubes.  The  drop-counter  con- 
sists of  a  glass  tube  of  medium  diameter,  tapering  at  its 
lower  extremity.  It  is  connected  with  the  container  by 
a  rubber  tube  of  15  cm.,  which  is  provided  towards  its 
middle  with  a  Murphy  screw  clamp,  serving  for  the  regu- 
lation of  the  drippage.  The  glass  tube,  of  an  external 
diameter   of   5   mm.    and   slightly   exceeding   in   length 


58     THE    TREATMENT    OF    FR  AC  TUBES 

(about  8  cm.)  the  total  hciglit  of  the  flask  with  its  rub- 
ber stopper,  is  connected  by  a  rubber  tube  to  the  curved 
glass  tube,  wliich  is  attached  to  the  upper  portion  of 
the  container.  By  plunging  this  tube  more  or  less 
deeply  into  the  container,  tlie  amount  of  the  overflow 
can  be  regulated.  It  also  serves  to  prevent  any  overflow 
in  case  of  obstruction  of  tlie  irrigation  tubes  of  the 
wound  or  of  the  siphon. 

The  siphon  consists  of  a  U-shaped  glass  tube  of  5  mm. 
external  diameter.  One  of  its  branches  plunges  down 
to  the  bottom  of  the  container.  The  other  longer 
branch  must  reach  about  5  cm.  below  the  bottom  of  the 
container.  To  this  siphon  is  attached  a  rubber  tube, 
wliich  Conducts  the  liquid  into  the  wound. 

Three  objections  have  been  raised  to  the  use  of  soda 
hypochlorite  solutions : 

(1)  Their  irritative  efl*ect  upon  the  skin. 

(2)  Their  brief  efficiency. 

(3)  The  necessity  of  uninterrupted  contact  with  all 
surfa.ces  of  the  wound. 

For  the  removal  of  these  and  other  minor  objections, 
tlie  dichloramin-T  in  oil  method  was  devised  by  Dakin. 
The  technic  is  greatly  simplified,  as  compared  to  the 
hypochlorite  procedure,  and  the  quantity  of  dressing 
material  needed  is  reduced  by  more  than  two-thirds.  It 
is  probable  that  the  newer  method  would  have  replaced 
the  hypochlorite  solutions,  but  for  superior  results  in 
war  practice  obtained  from  the  latter  and  their  specially 
trained  hospital  staffs.  In  civil  experience,  the  results 
of  the  dichloramin-T  in  oil  method  surpassed  those  of 
tlie  hypochlorite  method. 

Dichloramin-T  in  Oil  Method 

The  chemical  name  of  the  double  chloramin  used  is 
paratoleum  hypochlorite  (toluene-parasulphondichlora- 
min).  Commercially,  it  is  known  as  chlorazene.  The 
germicide  is  dissolved  in  chlorinated  eucalyptol  instead 


GENERAL   SURVEY  59 

of  water,  because  synthetic  chloramins  will  rapidly  form 
inactive  compounds  with  tissue  proteins  in  the  wound 
exudate.  Similarly,  chlorinated  liquid  paraffin  may  be 
added.  The  oils  are  chlorinated  to  limit  their  decom- 
posing' action  on  the  dichloramin-T.  The  dissolving  of 
the  dichloramin-T  in  chlorinated  eucalyptol  insures  a 
very  gradual  liberation  of  the  bactericide,  extending 
over  18  to  24  hours,  instead  of  the  30  to  60  minutes' 
activity  of  the  hypochlorite  solutions. 

It  is  claimed  that  .  the  rate  of  decomposition  6i 
dichloramin-T  in  eucalyptol  in  a  colored  bottle  is  only 
-^5  per  cent,  for  the  period  of  one  month.  In  addition 
to  its  stability,  this  synthetic  double  chloramin  com- 
pound has  the  advantage  over  the  hypochlorite  solu- 
tion of  being  non-irritating  to  the  skin.  Application  of 
the  dichloramin-T  in  oil  once  m  24  hours  is  sufficient. 
The  method  permits  of  dependent  drainage. 

The  basis  of  dichloramin-T  is  para-toluene-suljyho- 
chlorate,  a  by-product  in  the  manufacture  of  saccha- 
rine. 

The  solution  can  be  prepared  by  any  reliable  chemist. 

First  Method  of  Preparing  Dichloramin-T. — 
Chlorinated  lime  (from  350  to  400  gm.)  of  good  qual- 
ity is  shaken  with  two  liters  of  water  on  a  shaker  for 
half  an  hour,  and  the  mixture  is  then  allowed  to  settle. 
The  supernatant  fluid  is  siphoned  off  and  the  remain- 
der filtered.  Powdered  toluene-parasulphonamid,  75 
gm.  (the  crude  product  may  be  used),  is  then  added 
to  the  whole  of  the  hypochlorite  solution  and  shaken 
till  dissolved.  The  mixture  is  filtered,  if  necessary, 
placed  in  a  large  separating  funnel,  and  acidified  by  the 
gradual  addition  of  Acetic- acid  (100  c.c).  Chloroform 
(about  100  c.i;».)  is  then  added  to  extract  the  dichlara- 
min,  and  the  whole  is  well  shaken.  The  chloroform 
layer  is  tapped  afF,  dried  over  calcium  chloride,  filtered, 
and  allowed  to  evaporate  in  the  air.  The  residue  is 
powdered  and  dried  in  vacuo.  It  is  sufficiently  pure 
for  most  purposes,^  without  recrystallization. 


60     TEE    TREATMENT    OF   FRACTURES 

The  sodium  toluene-parasulphochloramin,  which  is 
sold  under  the  trade  name  of  chlorazene,  may  be  used 
instead  of  the  toluene-parasulphonamid. 

Second  Method  of  Preparing  Dichloramin-T. — 
Fifty  gm.  of  para-toluene  sulphonamid  are  dissolved 
in  500  c.c.  of  water,  and  100  gm.  of  sodium  acetate  and 
100  c.c.  of  chloroform  are  added.  The  container  is  im- 
mersed in  cold  water,  and  a  rapid  stream  of  chlorine  is 
passed  in  until  the  mixture  is  saturated.  The  mixture 
is  allowed  to  stand  a  few  hours,  and  if  the  odor  of 
chlorin  disappears,  more  of  the  gas  is  passed  in.  If 
necessary,  more  chloroform  can  be  added  to  dissolve 
the  dichloramin.  From  this  point  on  the  procedure  is 
the  same  as  in  the  preceding  method. 

Preparation  of  Chlorinated  Eucalyptol. — Eu- 
calyptol,  not  eucalyptus  oil,  must  be  used.  Five  hun- 
dred c.c.  are  treated  with  15  gm.  of  potassium  chlorate 
and  50  c.c.  of  concentrated  hydrochloric  acid.  After 
twelve  hours  the  oil  is  well  washed  with  water  and 
sodium  carbonate  solution.  Dry  sodium  carbonate  is 
added  to  the  oil,  and  the  mixture  is  allowed  to  stand  24 
hours.  It  is  then  filtered  and  dried  with  a  little  calcium 
chlorid. 

Preparation  of  Chlorinated  Paraffin  Oil. — Five 
hundred  c.c.  of  commercial  liquid  petrolatum  are 
treated  with  15  gm.  of  potassium  chlorate  and  50  c.c. 
of  concentrated  hydrochloric  acid.  The  mixture  is  ex- 
posed to  the  light  and  allowed  to  stand  over  night.  It 
is  then  put  into  a  separatory  funnel,  and  washed  suc- 
cessively with  water,  sodium  chloride  solution,  and 
water.  The  opalescent  oil  is  tapped  off,  a  lump  or 
two  of  calcium  chloride  and  5  gm.  of  charcoal  are 
added,  and  the  oil  is  filtered  with  suction. 

Concerning  the  amount  of  liquid  petrolatum  which 
can  be  added  to  the  eucalyptol  solution  of  dichlora- 
min-T,  Dakin  found,  on  the  basis  of  experimental  evi- 
dence, that  for  solutions  destined  to  be  kept  for  any 
length  of  time  no  more  than  an  equal  part  of  liquid 


GENERAL   SURVEY  61 

petrolatum  should  be  added  to  a  15  per  cent,  solution 
of  dichloramin-T  in  eucalyptol.  Mixtures  destined  for 
immediate  use  may  contain  as  much  as  two  parts  of 
liquid  petrolatum  to  one  part  of  the  15  per  cent,  eu- 
calyptol solution.  In  his  work,  a  solution  was  used 
made  up  of  one  part  of  liquid  petrolatum  and  two  parts 
of  15  per  cent,  solution  of  the  dichloramin-T  in  eu- 
calyptol. 

Employment  of  Dichloramin-T.  —  The  simple 
technique  is  carried  out  as  follows :  A  careful  surgical 
trimming  of  the  wound  is  done  at  the  primary  dressing. 
All  infected  and  suspicious  foci  are  excised,  and  all 
dead  or  dying  tissues  are  cut  away.  Superficial  wounds 
arc  exposed  to  the  action  of  dichloramin-T  by  means 
of  a  spray  atomizer.  Into  deep  wounds  the  germicidal 
liquid  is  poured  as  into  a  cup.  Wounds  with  two  open- 
ings are  treated  in  the  same  manner,  the  lower  orifice 
having  been  temporarily  closed  with  gauze,  which  is, 
after  the  treatment  is  removed,  for  the  re-establishment 
of  dependent  drainage,  a  powerful  physiological  ally  in 
the  fight  of  the  organism  against  the  infection.  Only 
a  few  layers  of  gauze  should  serve  as  wound  coverings, 
so  that  the  oil  may  be  taken  up  by  the  dressings.  One 
daily  application  of  dichloramin-T  in  oil  is  sufficient. 
A  renewal  of  the  treatment  is  not  required  before  the 
end  of  twenty-four  hours,  for  large  deep  wounds,  while 
one  dressing  for  every  48  to  72  hours  suffices  for 
simpler  or  more  superficial  wounds.  All  wound  pockets 
and  recesses  are  reached  by  the  oily  solution  of  dichlora- 
min-T. Infected  tracts  and  recesses  can  be  wiped  out 
by  means  of  cotton  swabs  dipped  into  the  solution. 

Ordinary  hard  rubber  or  all-glass  spray  atomizers 
should  be  used.  Chlorine  attacks  metals,  so  that  metal 
atomizers  are  not  recommended.  Irrigation  tubes  are 
unnecessary,  as  the  dichloramin-T  solution  contains  an 
abundance  of  available  chlorine  and  does  not  have  to  be 
renewed  every  few  hours. 

The  conclusions  arrived  at  by  Professor  Sweet,  work- 


62  THE    TREATMENT    OF    FRACTURES 

ing  with  the  United  States  Army  Base  Hospital  No.  10, 
in  France,  show  that  Dakin's  dichloramin-T,  in  solution 
in  eucalyptol  and  paraffin  oil,  is  of  great  advantage  in 
wound  treatment,,  because : 

(1)  It  saves  the  pain  of  wound  dressing. 

(2)  It  effects  an  appreciable  saving  of  dressing  ma- 
terial. 

(3)  The  amount  of  solution  needed  is  of  small  bulk. 

(4)  The  number  of  wounds  which  a  surgeon  can 
dress  in  a  given  time  is  far  greater  than  by  any  other 
method. 

(5)  The  elimination  of  the  Garrel  tube  simplifies  the 
dressing  and  the  problem  of  transportation  of  the 
wounded. 

(6)  The  elimination  of  the  Carrel  tube  saves  the 
time  taken  by  the  nurse  for  the  periodic  flushing. 

Dichioramin-T  is  a  stable  product,  and  its  solutions 
have  been  kept  in  the  dark  for  13J2  days,  remaining 
practically  unchanged;  when  exposed  to  daylight,  the 
strength  was  only  very  slightly  diminished.  Other  ad- 
vantages, aside  from  its  strongly  bactericidal  action, 
are  its  high  solubility  in  water,  which  enhances  its  prac- 
tical usefulness,  and  its  freedom  from  coagui^jting 
properties  toward  proteid  matter.  Necrotic  tissue  is 
dissolved  by  the  chlorin  in  dichloramin-T,  and  reliable 
hemostasis  must  be  secured  by  vascular  ligature,  in  order 
to  guard  against  disintegration  of  the  clot  and  second- 
ary hemorrhage. 

Preparation  of  Chloramin  Solution. — Dissolve 
140  grams  (dry)  of  sodium  carbonate,  or  400  grams 
of  the  crystallized  salt,  in  ten  liters  of  tap  water.  Add 
200  grams  of  chloride  of  lime.  Shake  the  mixture,  and 
after  half  an  hour  siphon  off  the  clear  liquid  from  the 
precipitate  of  calcium  carbonate  and  filter  through  a 
cotton  plug.  Add  40  grams  boric  acid  to  the  clear  fil- 
trate. The  solution  is  now  ready  for  use,  and  should 
not  be  kept  longer  than  a  week.     It  contains  0.5.  to  0.6 


GENERAL    SURVEY  63 

per  cent,  hypochlorous  acid.  (Prof.  Colicn,  of  tlie  Uni- 
versity of  Leeds.) 

Chloramin  paste  contains  8  per  cent,  of  sodium  stea- 
rate  and  4  to  15  parts  per  1,000  of  chloramin-T. 

Preparation  of  Chloramin  Paste. — Boil  a  liter  of 
distilled  water  and  add  80  grams  of  stearic  acid.  When 
this  has  melted,  gradually  add  enough  caustic  soda  to 
saponify  the  fatty  acid,  and  after  complete  solution 
add  4  to  10  gm.  of  chloramin-T,  according  to  tlic  con- 
centration desired.  The  mixture  is  then  placed  in  a 
mixing  machine  and  shaken  until  thoroughly  cooled. 
The  paste  is  a  smootli,  snow-white  cream.  It  is  found 
by  Daufresne  to  be  sufficiently  active  and  stable  for  use 
in  the  treatment  of  wounds  and  for  tlic  promotion  of 
wound  sterilization. 

Chloramin  is  a  highly  reactive  substance,  and  sliould 
not  be  used  in  combination  witli  otlier  antiseptics.  It 
decomposes  alcohol  as  well  as  hydrogen  peroxide. 

Technique  for  the  Application  of  Chloramin  Paste. — 
"The  chloramin  paste  is  designed  to  maintain  in  an 
aseptic  condition  wounds  wlilch  have  already  been  dis- 
infected, or  to  sterilize  slightly  infected  wounds.  It 
should  only  be  applied  to  wounds  wlrlch  yield  small 
quantities  of  secretion,  have  little  or  no  necrotic  tissue, 
and  little  or  no  infection.  Neutral  sodium  olcate  is 
poured  on  to  the  wound  and  the  surrounding  skin  from 
a  flask  with  ;i  small  opening.  The  granulations,  the 
epithelial  edges,  and  the  skin  are  gently  swabbed  with 
a  piece  of  absorbent  cotton  attached  to  a  forceps.  By 
tills  means  an  excellent  cleansing  process  is  effected. 
The  patient  should  feel  no  pain  :  any  suffering  indicates 
either  tliat  the  sodium  olcate  Is  Incorrectly  prepared  or 
that  the  cleansing  Is  imperfectly  carried  out.  The 
sodium  olcate  is  removed  with  a  plug  of  cotton  soaked 
in  water,  and  the  surface  of  the  skin  is  dried  by  care- 
fully applying  a  compress  of  absorbent  gauze.  A  suffi- 
cient quantity  of  chloramin  paste  is  withdrawn  from 
the  receptacle  by  means  of  a  sterilized  wooden  spatule 


64  THE    TREATMENT    OF    FRACTURES 

and  applied  to  the  surface  of  the  wound  to  the  thickness 
of  at  least  1  cm.  It  should  cover  not  only  the  granu- 
lations, but  also  the  epithelial  edges  and  part  of  the 
surrounding  skin-  If  the  wound  is  deep  and  anfractu- 
ous, the  tube  containing  the  chloramin  paste  is  intro- 
duced into  the  opening,  and  sufficient  chloramin  paste 
is  expressed  to  fill  the  cavity.  But  no  pressure  should 
be  applied  during  the  process.  A  compress  of  dry 
gauze,  which  should  be  much  larger  than  the  wound 
itself,  is  next  placed  over  the  chloramin  paste.  The 
compress  is  applied  to  the  surface  of  the  skin  and  at- 
tached to  it  by  means  of  two  or  three  strips  of  adhesive 
plaster.  It  is  important  that  the  gauze  should  be  placed 
exactly  over  the  wound,  for  if  the  bandage  is  shifted 
the  gauze  will  introduce  bacteria  from  the  surrounding 
skin  on  the  surface  of  the  granulations  and  reinfection 
will  ensue.  Above  the  gauze  is  placed  a  piece  of  ab- 
sorbent cotton  enveloped  in  gauze.  The  dressing  must 
not  be  compressed  by  bandages  and  should  be  renewed 
every  24  hours.  The  wound  is  washed  out  with  sodium 
oleate  every  day  or  two,  depending  on  the  condition  of 
the  skin.  The  application  of  cliloramin  should  be  pain- 
less;  any  sensation  of  pain  signifies  technical  error  on 
the  part  of  the  surgeon.  The  bacteriological  condition 
of  the  wound  is  examined  every  day  in  film  preparations 
of  secretions  taken  from  various  parts  of  the  wound." 
(Carrel  and  Hartmann,  Jrl.  Exp.  Med.,  July  1,  1917, 
p.  95.) 

Stable  hypochlorite  solutions  can  now  be  obtained 
without  the  need  of  a  chemist  to  watch  the  titration,  by 
looking  in  surgical  periodicals  for  the  advertisements 
of  large  and  reliable  manufacturing  houses,  which  have 
devised  various  methods  for  the  preparation  of  the 
Carrcl-Dakin  fluid  and  other  solutions  for  the  disinfec- 
tion of  wounds. 

Preparation  of  Modified  Hypochlorite  Solution. — 
Extract  25  grams  of  pure  calcium  hypochlorite  with  a 
sufficient  amount  of  water  at  a  temperature  of  50°  C. 


GENERAL    SURVEY  65 

to  yield  finally  1,000  c.c.  of  solution.  After  filtration, 
add  8  grams  of  sodium  chloride  or  12  grams  of  mag- 
nesium chloride,  then  gradually  2  to  8  grams  of  lactic 
or  phosphoric  acid,  until  the  solution  becomes  slightly 
acid. 

This  preparation  can  be  employed  warm  and  is  use- 
ful in  the  prevention  of  suppuration  in  presumably 
infected  wounds. 

Preparation  of  Magnesium  Hypochlorite  Solution. — 
Dissolve  190  grams  of  magnesium  sulphate  in  two  liters 
of  water,  and  let  the  mixture  act  on  100  grams  of  cal- 
cium chloride  which  have  also  been  mixed  with  two 
liters  of  water.  Then  filter,  in  order  to  separate  the 
resulting  precipitate  of  calcium  sulphate.  Let  stand 
until  this  precipitate  has  become  entirely  settled  to  ob- 
tain a  clear  solution. 

The  employment  of  this  disinfecting  fluid  is  recom- 
mended on  account  of  its  strong  antiseptic  power,  its 
non-caustic  character  in  efficient  dosage,  its  small  cost, 
and  its  easy  preparation.  An  excess  of  free  magnesium 
is  readily  tolerated  by  the  organism,  in  contradistinc- 
tion from  free  soda  or  lime. 

Soap  solutions  (common  yellow  soap,  or,  better,  soft 
green  soap  of  the  British  Pharmacopoeia,  in  9^/2  per 
cent,  solution)  have  been  used  with  the  Carrel  tubes 
for  wound  treatment  in  the  Casualty  Clearing  Stations, 
with  satisfactory  results.  In  addition  to  their  cheap- 
ness, these  dressings  are  claimed  to  be  much  less  painful 
than  ordinary  dressings,  and  require  to  be  changed  only 
once  in  three  or  four  da3^s. 

''Javelle  Water"  in  the  Treatment  of  War  Wounds 

The  commercial  preparation  known  as  "Javclle 
(more  correctly  Javel)  Water,"  a  solution  of  chlorin- 
ated potassa,  was  at  first  considered  as  valueless  in 
tlie  treatment  of  infected  war  wounds,  on  account  of  its 


66     THE    TREATMENT    OF    FRACTURES 

irritant  properties  in  moderately  strong  solutions.  Re- 
cent investigations,  by  Cazin  and  Krongold,  have 
shown,  however,  that  a  solution  of  15  grams  Javelle 
water  for  each  liter  of  water  (  containing  only  0  gr.  042 
per  hundred  of  sodium  hypochlorite,  or  15:1.000), 
is  well  adapted  to  surgical  purposes.  This  15  :1.000  so- 
lution showed  a  bactericidal  power  superior  to  that  of 
Dakin's  fluid,  the  irritant  properties  of  which  are 
probably  due  to  an  excessive  proportion  of  sodium  hy- 
pochlorite. In  the  Messimy  Hospital  the  treatment  of 
510  cases  of  wound  infection — including  155  compound 
fractures  and  286  deep  wounds  of  soft  parts,  for  the 
most  part  with  very  extensive  lesions — with  Javelle 
water  led  to  recovery  of  all  but  three  of  the  patients, 
or  507  recoveries.  (La  Presse  Medicale,  I,  Nov.,  1917, 
p.  632.) 

Preparation  of  Javelle  Water. — 

Potassium  Carbonate  . 58  gm. 

Chlorinated  Lime    80  gm. 

Water  {a  sufficient  quantity  to 
make  about  one  thousand  mil- 
liliters)     1000  mils. 

JMix  the  chlorinated  lime  intimately  with  four  hun- 
dred milliliters  of  water.  Dissolve  the  potassium  car- 
bonate in  three  hundred  milliliters  of  boiling  water,  and 
pour  the  hot  solution  into  the  mixture  first  prepared. 
Shake  the  flask  or  bottle  well,  stopper  it,  set  aside  to 
cool,  and  then  add  sufficient  water  to  make  the  product 
measure  one  thousand  milliliters  and  filter.  Keep  the 
solution  in  well-stoppered  bottles,  in  a  cool  place  and 
protected  from  the  light. 

For  use  in  wound  treatment,  dilute  the  fluid  to  a 
strength  of  15:1.000  parts  of  water.  This  dilution,  as 
fehown  by  the  French  observers,  makes  a  very  practical 
solution,  although  Javelle  water  was  at  first  thought 
to  be  inapplicable  on  account  of  its  excessive  alkalinity 
and  irritaht  properties. 


GENERAL    SURVEY  67 

In  connection  with  the  alleged  occurrence  of  second- 
ary hemorrhage  under  certain  modem  forms  of  wound 
treatment,  Bashford  endeavored  to  ascertain  the  effect 
of  immersion  of  living  tadpoles  in  various  dilutions  of 
chloramin,  Dakin's  solution,  eusol  and  flavine.  For 
control,  parallel  experiments  were  made  with  iodin  and 
mercury  perchloride.  It  was  found  that  chloramin,  as 
compared  to  hypochlorite  and  euscl,  is  relatively  less 
toxic  to  the  animal.  With  hypochlorite,  eusol,  and 
chloramin,  it  is  possible  to  separate  the  bactericidal 
effects  upon  the  surface  from  the  life-destroying  action 
on  the  animal.  With  flavine  in  its  strongest  concen- 
tration, iodin,  and  mercury  perchloride,  the  surface 
sterilization  and  life-destroying  effect  are  inseparable. 
The  local  action  of  hypochlorite  is  apparently  coun- 
teracted by  an  active  circulation,  which  may  be  cred- 
ited with  a  nutrient  role,  as  a  provider  of  protein,  or 
with  the  mechanical  removal  of  the  hypochlorites  before 
they  can  unite  with  and  thereby  destroy  the  living  tis- 
sues. Simply  expressed,  an  efficient  circulation  pre- 
vents the  penetration  of  the  chemically  unstable  hypo- 
chlorite solutions  into  living  tissue. 

Hypochlorons  Acid  Preparations — Eusol  and  Eupad 

The  antiseptic  action  of  hypochlorous  acid,  and  its 
application  to  wound  treatment,  was  pointed  out  in 
1915  by  Lorrain  Smith,  Dremman,  Rettie,  and  Camp- 
bell, of  the  Department  of  Pathology  in  the  University 
of  Edinburgh.  This  hypochlorous  solution  is  known 
as  Eusol,  which  is  standardized  at  0.5  per  cent,  of 
hypochlorous  acid,  and  was  originally  prepared  on  a 
large  scale  from  dry  bleaching  powder  and  boric  acid. 
In  smaller  quantities,  eusol  is  advantageously  prepared, 
at  a  moment's  notice,  by  diluting  and  mixing  two  stable 
stock  solutions,  as  follows : 

Preparatio7i  of  Fmsol. — Take  135  c.c.  of  liquor  calcis 
chlorinatfle  (a  10  per  cent,   solution  of  bleaching  pow- 


68  THE    TREATMENT    OF    FRACTURES 

der  in  water);  dilute  with  water  to  1  liter;  add  10 
grams  of  boric  acid,  and  shake  up  till  dissolved.  The 
solution  remains  clear,  and  without  further  treatment 
is  ready  for  use.  If  preferred,  a  saturated  solution  of 
boric  acid  may  be  stocked  at  room  temperature ;  this 
contains  4  per  cent,  boric  acid,  therefore  250  c.c.  gives 
the  amount  required  for  1  liter  eusol.  In  making  eusol 
in  this  way,  the  135  c.c.  of  liquor  calcis  chlorinatae 
should  be  diluted  to  750  c.c.  and  the  250  c.c.  of  boric 
acid  solution  added.  This  prevents  the  formation  of 
the  precipitate  which  occurs  if  boric  acid  be  added  to 
undiluted  liquor  calcis  chlorinatse. 

Preparation  of  Eusol  for  Intravenous  Injection  in 
Septiccemia. — For  this  purpose,  it  is  necessary  to  add 
sodium  chloride  in  the  proportion  of  8.5  grams  to  the 
liter.  In  this  case,  therefore,  the  185  c.c.  of  liquor  cal- 
cis chlorinata?  would  be  diluted  to  500  c.c.  with  distilled 
water,  the  250  c.c.  boric  acid  solution  added,  and  also 
a  solution  containing  8.5  grams  of  sodium  chloride  dis- 
solved in  250  c.c.  of  distilled  water. 

These  methods  of  preparing  eusol  were  published  in 
the  British  Medical  Journal,  September  22,  1917,  by  J. 
Lorrain  Smith,  Ritchie,  and  Rettie,  who  say  that  since 
liquor  calcis  chlorinata'  keeps  well,  the  method  described 
above  has  suggested  itself  as  a  simple  and  convenient 
way  of  prepai'ing  eusol  in  any  quantity  desired.  Each 
liter  of  the  liquor  yields  at  least  seven  liters  of  eusol. 

(The  quantities  given  in  the  prescription  are  calcu- 
lated on  a  chloride  of  lime  assaying  25  per  cent,  avail- 
able chlorine,  which  is  the  average  obtained  from  com- 
mercial samples  at  the  present  time.) 

Eusol  may  also  be  prepared  as  follows :  To  1  liter 
of  water  add  12.5  grams  of  bleaching  powder,  shake 
vigorously,  then  add  12.5  grams  boric  acid  powder  and 
shake  again.  Allow  to  stand  for  some  hours,  pref- 
erably over  night,  then  filter  off,  and  the  clear  solution 
is  ready  for  use. 


GENERAL    SURVEY  69 

This  solution  contains : 

PER  CENT 

Hjpochlorous  acid 0.54 

Calcium  Chlorate .' 1.^8 

Calcium  Chloride 0.17 

Total    ;  .  .    1.99 

Another  Method  of  Preparing  Eusol. — Shake  up  25 
grams  of  eupad  (equal  parts  of  commercial  bleaching 
powder  and  boric  acid,  intimately  mixed  and  ground 
in  a  mortar)  with  1  liter  of  water.  Let  stand  for  a  few 
hours,  then  filter  through  cloth  or  filter  paper.  Keep 
the  mixture  in  a  closely  stoppered  bottle,  and  do  not 
expose  to  light. 

Eupad  is  the  name  given  to  hypochlorous  acid  in 
powder  form,  and  consists  of  equal  weights  of  finely 
ground  bleaching  powder  (chloride  of  lime)  and  of  boric 
acid. 

Hypochlorous  solution,  electrically  produced  from 
In^pertonic  saline,  was  recommended  as  a  strongly  bac- 
tericidal disinfectant  for  septic  wounds,  by  Beattie, 
Lewin,  and  Gee  (Brit.  Med.  Jrl.,  I,  1917,'  p.  256). 
Their  apparatus  can  be  installed  in  any  hospital  or  in- 
stitution, and  a  supply  of  the  solution  produced  at  a 
very  small  cost.  The  lymph  flow  in  the  wound  is  en- 
couraged b}'^  the  hypertonic  solution  which  is  used  for 
the  production  of  the  hypochlorite.  Surface  bacteria 
on  septic  foci  seem  to  be  destroyed  almost  immediately, 
and  the  stimulating  action  on  the  lymph  flow  tends  to 
wash  to  the  surface  the  more  deeply  situated  organisms. 
This  lymph  increase  is  claimed  to  be  very  evident  in 
the  wounds  treated  with  this  solution. 

Mode  of  preparation  of  eusol,  according  to  Fraser 
and  Bates  (Jrl.  of  the  R.  Army  Med.  Corps,  Vol. 
XXVH,  1916,  p.  791):  "In  a  Winchester  quart  bot- 
tle twenty-seven  grams  of  dry  bleaching  powder  were 
placed,  and  to  this  one  liter  of  water  was  added ;  the 


70  THE    TREATMENT    OF    FRACTURES 

mixture  was  shaken,  and  twenty-seven  grams  of  boric 
acid  were  added  ;  the  bottle  was  now  filled  with  water, 
the  solution  was  thoroughly  shaken,  allowed  to  stand 
for  a  few  hours,  and  then  filtered  through  cotton  wool. 
The  clear  solution  is  eusol ;  it  is  slightly  alkaline  to 
litmus  and  it  contains  approximately  0.5  per  cent,  hy- 
pochlorous  acid.  The  solution  was  stocked  in  air-tight 
stone  jars." 

The  same  writers  report  most  gratifying  results  from 
intravenous  injections  of  eusol,  varying  in  amounts 
from  forty  cubic  centimeters  to  seventy  cubic  centi- 
meters in  cases  of  autotoxemia  subsequent  to  infection 
of  a  wound  with  gas-producing  organism. 

Packing  with  salt  sacks  (Gray's  metliod),  to  which 
eupad  powder  has  been  added,  is  advocated  in.  the  treat- 
ment of  septic  gunshot  wounds  on  the  basis  of  good  re- 
sults in  a  large  series  of  cases  by  Major  Hull,  of  the 
Royal  Army  iNIedical  Corps.  A  convenient  method  of 
combining  the  eupad  with  salt  is  to  pack  the  wound  with 
ordinary  salt  sacks  sterilized  in  the  autoclave  and  intro- 
duce into  the  middle  of  tlie  sacks  witliout  touching  the 
wound  an  unsterilizcd  sack  filled  with  eupad.  (Sacks 
filled  with  eupad  and  salt  in  the  proportion  of  one  to 
three  are  destroyed  in  the  autoclave  owing  to  the  cor- 
rosive action  of  the  hypochlorous  acid  upon  the 
fabric.)  The  solid  salt  sack  consists  of  a  two-walled 
sack  of  suitable  size,  made  of  bandage,  between  the  lay- 
ers of  which  four  layers  of  gauze  are  placed.  The  in- 
terior of  the  sack  is  filled  with  salt  and  the  tail  of  the 
bandage  forms  a  drain.  The  sacks  are  made  in  differ- 
ent sizes,  sterilized  in  an  autoclave  and  stored  ready 
for  use.  One  or  more  of  these  sacks  is  used  to  pack 
wounds,  the  spaces  between  the  sacks  being  filled  with 
gauze.  A  tube  of  perforated  zinc  or  rubber  may  be 
passed  into  the  depth  of  the  wound  in  case  of  large 
septic  wounds.  Six  days  may  be  said  to  be  an  aver- 
age time  for  the  sacks  to  remain  in  the  wound. 

"The  successful  results  of  this  treatment  largely  de- 


GENERAL    SURVEY  71 

pend,  as  all  treatment  of  septic  wounds  must,  upon  an 
early  attack  on  the  sepsis  and  upon  the  thoroughness 
with  which  it  is  possible  to  remove  septic  and  necrosed 

tissue." 

Hypertonic  Solutions   (Lymphagogic  Agents) 

Substances  which  produce  a  free  flow  of  lymph  from 
the  tissues  with  which  they  come  in  contact,  thereby  in- 
directly flushing  the  wound  and  diluting  the  toxins,  have 
been  recommended  in  the  treatment  of  infected  war 
wounds  by  Sir  Almroth  Wright  and  his  followers.  Al- 
though the  lymphagogic  effect  increases  in  proportion 
to  the  strength  of  the  salt  solution,  it  is  not  desirable, 
on  account  of  the  resulting  pain  and  irritation,  to  go 
beyond  ten  per  cent,  of  salt,  even  in  the  case  of  slougli- 
ing  wounds.  In  order  to  prevent  the  lymph  coagulat- 
ing on  the  siphon,  bandages,  and  on  the  walls  of  the 
wound  itself,  citrate  of  soda  is  employed  in  combina- 
tion with  hypertonic  salt  solutions.  Blood  mixed  with 
pus  is  prevented  from  clotting  by  five  per  cent,  of  salt 
mixed  with  0.5  per  cent,  of  citrate  of  soda.  For  the 
sole  purpose  of  irrigation  and  removal  of  pus,  the  cit- 
fate  is  unnecessary. 

In  order  to  encourage  a  free  outpouring  of  lymph 
from  the  whole  internal  and  external  surface  of  the 
wound.  Sir  Almroth  Wright  proposed  an  arrangement 
of  bandages  by  means  of  which  the  irrigating  fluid  can 
be  led  into  the  wound  where  it  is  required ;  be  distributed 
so  as  to  wash  down  all  walls  ;  and  then  be  carried  away 
without  any  leakage  into  the  bed.  Loops  of  sterile 
bandages,  previously  soaked  in  a  solution  of  5  per  cent, 
sodium  chloride  and  0.5  per  cent,  sodium  citrate  are 
introduced  into  the  wound,  after  this  has  first  been 
syringed  out  with  the  solution.  The  free  ends  of  the 
bandage  are  carried  out  from  the  wound,  to  be  inserted 
between  plies  of  lint  well  soaked  in  the  solution  and 
folded  over  so  as  to  form  a  thick  pad.  Finally,  one 
or  two  tabloids  of  salt  ought  to  be  placed  in  between 


72     THE    TREATMENT    OE    FRACTURES 

the  ^ack  layers   of  the  pad,   and  over  the   top   of  all 
ought  to  come  a  layer  of  impervious  protective  tissue. 

Formula  of  Wrighfs  Solution 

Sodium  citrate 0.50  centigr. 

Sodium  chloride   .  , 0.30  centigr. 

Distilled  water 100  grams 

The  employment  of  this  "antiseptic  anodyne"  yielded 
excellent  results  in  the  experience  of  Dickinson,  who  has 
used  it  for  two  years  in  all  sorts  of  cases,  the  wounds 
remaining  clean  and  healing  more  rapidly  than  under 
the  use  of  any  other  liquid. 

Sir  Almroth  Wright  says  with  regard  to  this 
lymphagogic  solution,  or  rather  with  regard  to  a  sim- 
ple 5  per  cent,  salt  solution,  which  he  finds  works  in 
most  cases  equally  well,  that  it  has  in  this  war  proved 
itself  permanently  useful.  When  brought  into  action 
upon  a  dry  and  infiltrated  wound,  or  a  wound  that  is 
foul  and  covered  with  slough,  it  resolves  the  indura- 
tion, brings  back  moisture  to  the  surfaces,  and  cleans  up 
the  wound  in  a  way  that  no  other  agent  does.  Applied 
in  gaseous  gangrene  in  the  form  of  a  wet  dressing  to 
incisions  which  have  been  carried  down  into  infected 
tissues,  it  causes  lymph  to  pour  out  of  the  wounds,  and 
arrests  the  spread  of  the  infection.  And,  again,  ap- 
plied in  gaseous  gangrene  to  an  amputated  stump  in 
cases  where  it  has  been  necessary  to  leave  infected  tis- 
sues behind,  it  reverses  the  lymph  stream  and  draws  out 
the  infected  lymph,  saving  life  in  almost  desperate  con- 
ditions. 

The  activity  of  salt  solutions  depends  on  this 
"phylacagogic"  character,  meaning  their  capacity  of 
bringing  the  protective  elements  of  the  body,  blood  fluid 
and  leukocytes,  into  application  in  the  wound. 

Salt  Pack  Method  of  Wound  Treatment 

The  salt  pack  treatment  of  wounds  was  introduced 
bv  Colonel  H.  M.  W.  Gray  (Brit.  Med.  Jrl.,  I,  1916, 


GENFAIAL    SURVEY  73 

p.  1)  for  the  purpose  of  promoting  a  lymphagogue  ac- 
tion and  obviating  the  need  for  elaborate  drainage  oi 
continuous  irrigation.  As  to  results  of  the  treatment 
with  salt  pack,  Donaldson  and  Joyce  write  in  The  Lan- 
cet of  September  22,  1917:  "The  adoption  of  this 
method  has  considerably  curtailed  the  patient's  period 
of  convalescence,  and  has,  moreover,  succeeded  where 
other  methods  have  failed,  including  the  much-advocated 
Carrel-Dakin  procedure." 

The  method  is  distinguished  by  its  simplicity,  the 
avoidance  of  daily  dressing  of  the  wound,  the  prompt 
development  of  healthy  surface  granulations,  and  rapid 
improvement  of  the  general  condition. 

Application  of  Tablet  and  Gauze  Packs. — "After  the 
wound  has  been  cleaned  by  operation,  all  the  recesses 
of  the  wound  (these  recesses  should  be  sought  out  by 
the  finger)   are  filled,  fairly  firmly,  with  gauze  wrung 
out  of  5  to  10  per  cent,  salt  solution,  in  the  folds  of 
which  are  placed  numerous  tablets  of  salt.     Bloodclots 
which  may   form  during  the  packing  should  be  wiped 
awa}^     The  gauze  should  be  packed  in  concertina-wise, 
a   tablet  being  placed   between    ever}^   third   or   fourth 
fold.     A  fairly  large,  fenestrated  rubber  tube  is  placed 
so  as  to  reach  to  the  deepest  part  of  the  main  cavity, 
which  is  then  filled  with  gauze  and  tablets.     The  dress- 
ing is  niade  flush  with  the  skin  and  the  tube  projects 
slightly    from    its    midst.       The    surrounding    skin    is 
painted  with  solution  of  iodine  or  other  antiseptic  ap- 
plication.    Two  or  three  layers  of  gauze  are  then  used 
to  cover  the  wound  and  surrounding  skin.     A  suitable 
amount    of    absorbent    ootton-wool    is    applied    and    a 
bandage  wound  on   smoothly  and  firmly.      Should  pus" 
collect  in  any  isolated  part  of  the  wound,  it  is  not  nec- 
essary  always  to   remove   the   whole  of  the  pack,   and 
thus    to    cause   the    patient    unnecessary    pain,    and    to 
jeopardize  the  healing  of  the  rest  of  the  wound.     Irri- 
gation and  drainage  of  the  affected  part  may  be  insti- 
tuted.     The   rest   of  the   'pack'   will  probably   become 


74  THE    TREATMENT    OF    FRACTURES 

loose  in  a  few  days.  If  it  is  suspected  that  any  part  of 
the  wound  will  give  trouble  in  this  way,  a  drain  down 
to  that  part  should  always  be  inserted." 

In  the  answer  to  questions  regarding  saline  treatment, 
sent  to  twenty-two  hospitals,  in  July,  1915,  tablet  and 
gauze  packs  were  judged  to  be  best  for  deep  and  fairly 
recent  wounds. 

Warm  solutions  of  sea  salt  or  common  salt,  in  a  con- 
centration of  seven  parts  in  a  thousand,  proved  useful 
for  the  immediate  treatment  of  war  wounds,  in  the  ex- 
perience of  Abadie  (Archiv.  de  Chir.,  Tome  XXIV,  No. 
5,  1915,  p.  162).  The  application  of  the  salt  is  pre- 
ceded by  careful  mechanical  cleansing  of  the  wound, 
which  is  then  freely  irrigated  with  the  physiological  so- 
lution and  finally  packed  with  gauze  strips  soaked  in  a 
concentrated  salt  solution.  For  convenience,  a  stock 
solution  of  140:1000  is  utilized,  which  represents  seven 
grams  of  salt  for  fifty  grams  of  water. 

Mode  of  Preparation. — Boil  a  liter  of  water  in  which 
have  been  placed  20  teaspoonfuls  of  common  salt.  Filter 
through  sterilized  cotton  into  a  previously  sterilized 
metal  container.  For  use,  pour  100  grams  of  the  stock 
solution  into  a  receptacle  containing  two  liters  of  boiled 
water. 

Magnesium  Chloride 

Solutions  of  magnesium  chloride  (.12,  1  0/00)  were 
shown  by  Delbet  to  exert  a  cytophylactic  action  on  the 
organism,  enormously  increasing  the  phagocytic  power 
of  the  white  blood  cells.  The  effect  seems  to  be  the 
more  marked  the  closer  the  cells  are  to  their  normal 
condition.  The  solution  is  non-toxic,  and  has  been  in- 
jected without  harm  into  the  veins  of  animals.  Used 
for  wound  dressings  and  in  subcutaneous  injections, 
magnesium  chloride  solution  appeared  efficient  in  Del- 
bet's  experience,  and  he  credits  this  treatment  with  the 
saving  of  a  soldier's  thigh  which  had  been  condemned 
to  amputation  on  account  of  arthritis  of  the  kneejoint, 


GENERAL    SURVEY  75 

with  shattering  of  the  patella  and  the  external  femoral 
condyle.      (Gazette  Medicale  de  Paris,  1915,  p.  70.) 

Physiological  chlorinated  solutions  of  sodium  or  mag- 
nesium chloride  are  recommended  by  Cruet  and  Rous- 
seau (La  Presse  Medicale,  XXVII,  No.  15.  1916,  p. 
116)  on  the  basis  of  favorable  clinical  experience,  such 
as  absence  of  wound  irritation,  rapid  disappearance  of 
infectious  foci,  prompt  cicatrization.  The  chlorinated 
solution  is  of  a  stable  composition  and  can  be  employed 
either  hot  or  cold. 

Preparation  of  Chlorinated  Salt  Solution. — To  250 
gr.  of  calcium  chloride  add  80  gr.  pure  sodium  chloride 
or  120  gr.  magnesium  chloride  in  one  half  liter  of  water 
at  50°.  The  resulting  homogeneous  milky  fluid  is 
poured  into  a  container  holding  ten  liters  and  filled  up 
with  water  at  50°.  The  fluid  is  siphoned  ofl*  and  fil- 
tered through  cotton  to  free  it  from  the  insoluble  sub- 
stances. Into  the  still  warm  fluid  pour  30  to  40  gr.  of 
lactic  or  phosphoric  acid  until  the  reaction  becomes  neu- 
tral or  slightly  acid.  Now  close  the  container,  to  guard 
against  the  giving  off'  of  hypochlorous  acid,  which  is 
to  yield  secondarily  the  corresponding  chloride.  The 
fluid  becomes  opaque  on  cooling  through  the  formation 
of  a  precipitate' of  acid  calcium  lactate  or  phosphate. 
Filter  the  fluid  when  it  is  cold  to  free  it  from  its  phos- 
phate. 

Mode  of  Employment. — The  solution  is  preferably 
employed  warm  (112  to  122°  Fahrenheit),  in  intermit- 
tent or  continuous  irrigation,  either  pure,  or  better, 
diluted  with  ordinary  salt  solution  or  warm  sterilized 
water.  Aside  from  irrigation,  the  chlorinated  solution 
ma}'^  be  applied  to  the  wound  in  form  of  moist  com- 
presses and  dressings. 

Sugar  Treatment  of  Wounds 

This  method  is  receiving  attention,  especially  on  the 
part  of  Italian  writers.     Clinical  experience  has  shown 


76     THE    TEE  ATM  E  NT    OF   FRACTURES 

that  a  prompt  effect  of  sugar  consists  in  diminution 
and  disappearance  of  the  purulent  wound  secretions, 
and  this  is  followed  by  the  disappearance  of  the  germs 
from  the  wound.  The  result  of  this  twofold  action  is 
the  transformation  of  a  septic  wound  into  a  healthy 
granulating  surface.  Although  wound  dressings  with 
concentrated  sugar  solutions  cause  a  diminution  and 
even  subsidence  of  suppuration,  the  discharge  in  the  first 
few  hours  is  slightly  increased,  due  to  the  osmotic  ac- 
tion set  up  by  the  presence  of  a  concentrated  sugar 
solution  on  the  wound.  This  flow  of  lymph,  far  from 
being  objectionable,  serves  on  the  contrary  for  the 
purification  of  the  wound.  The  favorable  effect  of  con- 
centrated sugar  solutions  on  infected  war  wounds  is  due 
to  their  local  vasoconstrictor  action  as  well  as  to  their 
antiseptic  properties. 

Collargol 

Collargcl  has  been  employed,  especially  in  German 
war  hospitals,  Avith  satisfactory  results  in  the  treatment 
of  septic  wounds  and  suppurating  tracts  or  bone  cavi- 
ties. Its  action,  like  that  of  all  colloid  substances,  is 
catalytic,  its  beneficial  effects  being  due  to  its  determina- 
tion of  a  powerful  leukocytosis.  Collargol  possesses 
no  true  bactericidal  power,  as  germs  can  live  and  mul- 
tiply  in  relatively  concentrated   solutions    (1:2000). 

The  physiological  methods  of  wound  treatment  in- 
clude the  use  of  ether,  suggested  by  Distaso  and  Bowen 
(Brit.  Med.  Jrl.,  I,  1917,  p.  259),  on  account  of  its 
marked  stimulating  power.  "In  the  cases  studied,  two 
constant  phenomena  were  observed,  namely,  the  very 
early  and  striking  appearance  of  large  firm  granula- 
tions (often  in  six  hours),  and  the  early  bleeding  of  the 
surface  of  the  wound."  The  wounds  are  firmly  swabbed 
when  dressed,  especially  those  with  cavities  or  deficient 
drainage.  Auto  disinfection  of  wounds  by  irrigation 
with  ether  solution  (2  per  cent.)  is  claimed  to  quicken 
the  healing  of  wounds  to  a  striking  degree. 


GENERAL    SURVEY  77 

Bipp  (Rutherford  Morison's  Method) 

The  name  was  chosen  by  Rutherford  Morison  for  rea- 
son of  brevity  and  because  it  indicates  the  constituents 
of  the  bismuth  iodoform  paraffin  paste.  Bipp  is  bis- 
muth subnitrate  or  carbonate,  1  part,  iodoform  2  parts, 
paraffin  in  quantity  sufficient  to  make  a  soft  paste. 

The  Morison  treatment,  in  conformity  with  the  most 
advanced  surgical  views,  consists  primarily  in  the  me- 
chanical removal  of  all  necrotic  material  and  tissue 
detritus  from  the  surface  and  interior  of  the  wound. 
Bloodclots,  wound  secretion,  bacterial  and  other  con- 
taminations are  removed  through  energetic  friction  of 
all  wound  recesses,  and  after  the  wound  has  been  dried 
with  alcohol,  the  antiseptic  paste  known  as  Bipp  is 
spread  over  tlie  wound  surface  and  rubbed  in.  The 
wound  is  then  sutured,  closed,  dressed,  and  left  to  itself 
for  about  twelve  days,  after  which  time  it  is  expected 
to  have  healed  or  nearly  so. 

Briefly,  this  treatment  consists  in  thorough  cleansing 
of  the  wound  and  its  surroundings,  followed  by  the  use 
of  antiseptics,  in  form  of: 

(cf)  Carbolic  lotion,  1 :20,  or  other  antiseptic  washes, 
for  the  skin. 

(fe)    Cleaning  with  alcohol  (methylated  spirit). 

(c)    Antiseptic  paste  (Bipp)  for  the  wound. 

Composition  of  Bipp  Paste 

Iodoform* : 440  grams 

Bismuth  subnitrate 220  grams 

Paraffin    220  grams 

M.  S.  A. 

The  bismuth  and  paraffin  are  sterilized  by  dry  heat 
at  a  temperature  of  120°  C.  for  half  an  hour;  the  bis- 
muth after  cooling  is  mixed  with  the  iodoform  in  a 
mortar  which  has  been  sterilized  by  means  of  boiling 
water  and  formalin.  The  paraffin  is  added  to  the  mix- 
ture at  a  temperature  of  90°   and  thoroughly  mixed. 


78     THE    TREATMENT    OF    FRACTURES 

then  put  into  specially  made  collapsible  tubes  with  noz- 
zle ends,  holding  40  to  80  grams.  The  paraffin  used 
should  be  semi-solid,  odorless,  and  tasteless,  melting- 
point  45°  C,  free  from  acidity  and  carbonizable  or- 
ganic impurities.  The  iodoform  snould  be  free  from 
moisture,  acids,  and  fixed  impurities.  It  is  also  neces- 
sary that  the  bismuth  be  chemically  pure,  free  from 
arsenic,  and  care  taken  in  sterilizing  that  the  tempera- 
ture does  not  rise  too  high,  otherwise  nitrous  fumes 
will  be  evolved.  A  paste  made  by  this  method  is  found 
to  be  fairly  solid  in  consistency,  shows  no  signs  of  sepa- 
ration or  decomposition,  and  is  perfectly  sterile. 

Modified  Formula  for  a  Paste  of  Softer  Consistency 

Iodoform    440  grams 

Bismuth  subnitrate 220  grams 

Paraffin  base    220  grams 

M.  S.  A. 
Paraffin  base : 

Paraffin  melting-point,  45° 19  parts 

Paraffin  lig.,  specific  gravity  880.  .    40  parts 

In  the  preparation  of  Bipp  paste  the  powders  are 
mixed  together  in  a  mortar,  and  the  liquid  paraffin  in- 
corporated. The  quantity  of  liquid  paraffin  required 
varies  according  to  the  bulk  of  the  powders,  the  bis- 
muth in  particular  being  liable  to  considerable  variation 
in  bulk.  A  sufficient  quantity  should  be  added  to  form 
a  paste.  It  is  then  advisable  to  rub  down  the  paste,  in 
small  quantities  at  a  time,  on  a  slab  with  a  spatula,  to 
insure  freedom  from  grit  and  dry  particles  of  powder. 

The  technic  of  application  is  very  definite  and  must 
be  carefully  carried  out  in  both  its  phases  : 

(1)  Under  an  anesthetic,  usually  open  ether,  cover 
the  wound  with  gauze  wrung  out  of  1  to  20  carbolic 
acid,  and  clean  the  skin  and  the  surrounding  area  with 
the  same  lotion. 


GENERAL    SURVEY  79 

(2)  Open  the  wound  freely,  and  if  possible  suffi- 
ciently to  permit  of  inspection  of  its  cavity. 

A  guide — a  finger  is  the  best  if  the  size  of  the  wound 
permits  of  it,  and  if  not  a  thick  probe — should  be  intro- 
duced to  the  bottom  of  the  wound  and  held  there  and 
fully  exposed.  In  doing  this,  special  regard  must  be 
paid  to  nerve  trunks  and  muscular  branches  of  nerves. 
Cleanse  the  cavity  with  dry  sterile  gauze  mops,  Volk- 
mann's  spoon,  etc.,  and  remove  all  foreign  bodies. 

(3)  Mop  the  surrounding  skin  and  the  wound  cavity 
with  methylated  spirit  and  dry  it. 

(4)  Fill  up  the  whole  wound  with  Bipp,  rub  it  well 
in  with  dry  gauze.  Then  remove  all  excess,  leaving 
only  a  thin  covering  over  the  wound  surface.  Dress 
the  wound  with  sterile  gauze,  and  cover  all  with  an  ab- 
sorbent pad,  which  is  held  in  position  by  sticking  plaster 
and  a  bandage. 

Though  it  is  desirable  to  see  the  bottom  of  all  wounds, 
it  may  be  occasionally  unwise.  A  through-and-through 
wound,  with  small  entrance  and  exit  openings,  may  be 
generally  cleansed  satisfactorily  by  passing  a  long  strip 
of  gauze  through  it  and  pulling  this  to  and  fro  as  a 
first  step,  next  by  doing  the  same  with  a  strip  of  spirit 
gauze,  and  finally  depositing  a  layer  of  Bipp  on  the 
inner  surface  of  the  wound  by  covering  a  long  strip 
of  gauze  with  the  paste,  passing  it  through  the  track 
and  rubbing  in  the  medicament  by  pulling  the  gauze 
backwards  and  forwards  again  and  again. 

The  only  possible  objection  to  the  free  use  of  Bipp 
as  an  application  to  open  wounds  is  the  liability  to 
absorption  and  production  of  iodoform  poisoning,  which 
has  been  noted  in  a  very  small  number  of  cases.  Idio- 
syncrasies against  iodoform  occur,  especially  among 
youthful  males. 

Sir  Berkeley  Moynihan,  in  a  recent  paper  on  surgical 
experiences  in  the  present  war,  says  that  Rutherford 
Morison's  method  is  widely  practised  in  the  base  hos- 
pitals  in  England,   and  by   many   surgeons   considered 


80  THE    TREATMENT    OF    FRACTURES 

the  'most  satisfactory  of  all.  This  method  of  wound 
treatment,  in  the  opinion  of  Sir  Alfred  Pearce  Gould 
(Brit.  Med.  Jrl,  II,  1917,  p.  677)  constitutes  the  high- 
est attainment  yet  achieved. 

The  following  results  have  been  obtained  by  means 
of  this  up-to-date  method  of  wound  treatment : 

(1)  Healing  of  large  infected  wounds,  without  spe- 
cial drainage,  and  without  change  of  dressings  up  to  a 
period  of  six  weeks, 

(S)  Safe  closing  of  such  wounds  by  sutures,  at  any 
stage  of  their  repair. 

lodated  Starch 

An  iodated  starch  solution,  which  seems  to  possess 
antiseptic  properties  analogous  to  those  of  Dakin's 
fluid,  has  recently  been  recommended  for  irrigation  of 
infected  wounds,  according  to  the  Carrel  method,  on 
the  basis  of  very  favorable  results,  by  Lumiere  (Jour- 
nal de  Med.  et  de  Chir.  Prat.,  November  10,  1917,  p. 
868).  This  solution  does  not  irritate  the  tissues,  so 
that  these  do  not  have  to  be  protected,  nor  does  it  bum 
the  bedding,  sheets,  etc.,  which  are  rapidly  ruined  by 
the  hypochlorite.     The  liquid  is  prepared  as  follows : 

Mode  of  Preparation  of  lodated  Starch  Solution 

Soluble  Starch 25  grams 

Boiling  water 1000  grams 

lodated  lodin  Solution,  1%.  ...        50  c.c. 

Flavine   (Acri-  and  Pro-fiavine) 

The  employment  of  antiseptics  such  as  flavine,  or 
brilliant  green,  is  not,  strictly  speaking,  a  modem 
method  of  wound  treatment,  the  novelty  feature  being 
represented  by  the  new  antiseptic  itself,  in  its  improved 
combination  of  highly  germinated  properties  with  in- 
off^ensiveness  towards  the  tissues  of  the  body. 

Flavine,  originally  named  trypaflavine,  on  account 
of  its  therapeutic  effect  on  trypanosome  infections,  is 


GENERAL    SURVEY  81 

chemically  diamin-methyl-acridinium  chloride.     As  one 
of*  the  acridine  series,  flavine,  for  technical  reasons,  is 
designated  as  acri-flavine.     Its  solution?  may  be  boiled 
or  heated  up  to  120°  C.  in  the  autoclave,  as  the  sub- 
stance is  a  fairly  stable  compound.     Great  expectations 
were  placed  on  it,  and  it  was  found  efficient  by  Ligat 
(who  for  some  time  used  flavine  exclusively  for  septic 
cases)  in  heavily  infected  wounds  with  free  drainage  of 
pus.      Mixtures   of  acridine   dyes   analogous  to   flavine 
also  yielded  some  good  results  in  the  treatment  of  septic 
war  wounds.     In  the  experience  of  Kellock,  who  injects 
one  to  two  drachms  of  a  1 :1000  solution  through  his 
modified  tubes  twice  in  24  hours,  the  use  of  flavine  was 
followed   by   very   satisfactory   results   in    some   highly 
septic  cases.      In  the  treatment  of  the  later  stages  of 
war  wounds,  however,  flavine  cannot  be  classed  as  a  suc- 
cess, although  it  apparently  has  its  uses  as  a  first  dress- 
ing.    The  abdominal  or  thoracic  cavities  will  tolerate 
considerable  amounts  of  flavine  solution  without  giving 
evidence  of  the  least  toxic  eff'ect.     Fleming  found,  how- 
ever, that  when  flavine  1  per  cent,  is  introduced  into  a 
closed  cavity  in  the  animal  body  it  loses  its  antiseptic 
power  within  two  hours,  and  he  points  out  that  much 
more   rapidly    then   will    the    1 :1000   solutions    recom- 
mended for  use  lose  their  potency. 

The  series  of  tests,  reported  by  Drummond  and  Mc- 
Nee  (Lancet,  II,  1917,  p.  640),  comprises  over  120 
wounds,  for  the  most  part  caused  by  fragments  of  shells 
or  bombs,  and  including  soft  parts  wounds,  compound 
fractures,  miscellaneous  regional  wounds  of  the  abdo- 
men, chest,  head,  and  joints.  A  number  of  the  cases, 
chiefly  compound  fractures  and  external  muscle  in- 
juries, were  treated  with  flavine  in  the  Carrel  method 
of  intermittent  irrigation;  the  perforated  tubes  were 
irrigated  with  the  solution  every  four  to  six  hours. 
Flavine  was.  at  first  employed  diluted  in  normal  saline 
solution,  in  which  the  powder  is  readily  soluble,  in  a 
strength  of  1:1000.      Later  on  it  was   found  that  the 


82     THE    TBEATMENT    OF    FRACTURES 

results  were  equally  good  when  the  stronger  solution 
for  the  first  dressing  was  followed  by  the  employment  of 
a  solution  of  1 :5000  for  all  later  applications.  In 
some  cases,  where  the  Carrel  irrigation  method  was 
used,  the  strength  of  the  solution  was  further  reduced 
to  1 :10,000. 

T]he  strong  bactericidal  properties  of  this  chlorine 
compound  were  first  pointed  out  by  Browning  and  Gil- 
mour.  But  the  claims  of  Browning  and  his  co-workers 
from  the  Bland-Sutton  Institute  of  Pathology  of  the 
Middlesex  Hospital,  London  (Brit.  Med.  Jrl.,  I,  1917, 
p.  73),  that  flavine  is  a  very  potent  germicide,  espe- 
cially in  the  presence  of  serum,  and  does  not  retard 
phagocytosis,  are  not  endorsed  by  Hewlett  (Lancet,  II, 
1917,  p.  493),  and  Fleming  (Brit.  Med.  Jrl.,  II,  1917, 
p.  341).  Criticizing  Browning's  technic,  Hewlett  shows 
that,  according  to  his  own  experiments  with  a  much 
larger  number  of  bacteria,  the  germicidal  value  of 
flavine  is  very  much  lower  than  was  originally  assumed. 
Fleming,  working  in  the  research  laboratory  of  a  base 
hospital  in  France,  found  that  flavine  has  a  very  de- 
structive effect  on  leukocytosis,  and  that  if  the  action 
on  leukocytes  and  bacteria  be  each  tested  for  24  hours 
its  leukocidal  action  is  far  in  excess  of  its  bactericidal 
action.  According  to  his  findings,  flavine  in  1 :500  so- 
lutions is  usually  unable  to  sterilize  in  24  hours  an 
equal  volume  of  pus  from  a  wound,  there  evidently  be- 
ing something  in  pus  which  prevents  the  action  of  flavine 
on  the  microbes,  presumably  because  it  is  absorbed  by 
the  pus  cells,  which  have  a  greater  attraction  for  flavine 
than  have  the  microbes.  A  persistent  infection  with 
coliform  bacilli  is  noted  in  the  later  stages  of  war 
wounds  treated  with  flavine  preparations,  and  pyo- 
cyaneus  infections  are  likewise  common. 

The  mode  of  application  of  flavine  will  be  considered 
under  the  heading  of  proflavine. 

Proflavine. — ^Proflavine  is  a  preliminary  product 
in   the   manufacture   of  acriflavine,   or   flavine,   and   its 


GENERAL    SURVEY  83 

preparation  is  therefore  more  simple  and  less  expen- 
sive. It  was  tested  by  McNee,  Hadden  and  McCartney, 
in  a  mobile  laboratory,  following  the  same  plan  as  in 
.  the  testing  of  acriflavine.  A  series  of  43  cases,  and 
altogether  60  wounds,  with  a  large  percentage  of  very 
severe  injuries,  were  treated  with  proflavine.  These 
cases  were  under  the  care  of  the  surgical  officers  of  a 
Casualty  Clearing  Station,  and  included  seven  injuries 
of  large  joints,  ten  severe  compound  fractures  of  limbs, 
and  four  lesions  of  large  blood  vessels  (with  special 
reference  to  the  vascular  injuries;  after  dealing  with 
the  vessels,  all  the  wounds  were  completely  sewn  up  after 
treatment  with  proflavine,  and  all  healed  without  the 
least  trouble).  The  outcome  of  the  tests  showea  no 
difference  in  the  properties  of  acriflavine  and  proflavine. 
Mode  of  Application  of  Flavine  (Acriflavine  and 
Proflavine). — The  employment  of  these  antiseptics  must 
be  preceded  by  the  excision  of  all  traumatized  tissue, 
with  careful  mechanical  cleansing  of  the  wound.  In  or- 
der to  guard  against  agglutination  of  the  red  blood 
cells,  flavine  solutions  should  not  be  used  in  stronger 
concentration  than  1 :1000.  A  flavine  solution  oi 
1  :1000  in  normal  saline  serves  for  the  primary  appli- 
cation, followed  later  by  the  use  of  a  more  dilute  solu- 
tion of  1 :5000  or  still  weaker  concentration.  To  large 
open  wounds,  flavine  may  be  applied  in  form  of  gauze 
soaked  in  the  solution  as  a  first  dressing,  which  need 
not  be  changed  for  two  to  three  days. 

Brilliant  Green,  Paste  and  Lotion 

Brilliant  green  is  chemically  a  triphenylmethane 
compound ;  commercial  brilliant  green  is  the  sulphate. 
Substances  of  this  class  possess  a  very  strong  activity 
against  wound  infections  with  cocci,  whereas  B.  coli 
infections  occasionally  prove  intractable.  Brilliant 
green  stimulates  the  formation  of  healthy  nodular 
granulation   tissue,   which   is   characterized   by   its    ex- 


84     THE    TREATMENT    OF   FRACTURES 

uberance  and  its  bright  red  color,  and  the  employment 
of  brilliant  green  paste  has  been  suggested  as  possibly 
useful  for  promoting  the  filling  up  of  large  deep  wound 
cavities. 

Composition  of  Brilliant  Green  Paste. — -This  non- 
poisonous  paste,  which  was  introduced  by  Captain  Wil- 
son Hey  into  the  treatment  of  infected  war  wounds,  is 
composed  of  boric  acid,  liquid  paraffin,  French  chalk 
and  brilliant  green. 

Mode  of  Application. — -As  pointed  out  by  Captains 
Rendle  Short,  Arkle  and  King,  the  paste  is  only  to  be 
applied  when  it  can  be  applied  completely.  They  find 
that  Hey's  method  of  staining  the  wound  by  injecting 
through  a  Carrel's  tube  with  a  1 :200  watery  solution 
of  brilliant  green  is  a  very  valuable  aid  to  complete 
excision.  Brilliant  green  paste  should  be  reserved  for 
such  cases  in  which  the  wound  can  be  freely  opened  and 
excised,  with  removal  of  all  foreign  bodies.  The  wound 
ought  to  be  dry  and  not  bleeding,  but  a  certain  amount 
of  oozing  can  be  checked  by  a  gauze  plug,  preferably 
paraffin  gauze,  which  is  easier  to  remove.  The  paste 
should  be  rubbed  in  thoroughly.  It  soon  washes  off 
the  skin  or  gloves.  The  wound  need  only  be  dressed 
about  once  in  four  days.  The  application  of  the  paste 
is  painless. 

In  the  great  majority  of  cases,  in  the  experience  of 
the  above-mentioned  observers,  the  wound  was  almost 
completely  sterilized  by  brilliant  green  paste  in  three 
days,  permitting  the  performance  of  secondary  suture 
even  in  large  wounds  complicated  by  bone  injury.  Small 
completely  excised  wounds  can  be  primarily  sutured 
after  the  application  of  brilliant  green. 

"By  this  method  we  have  been  able,  with  fair  con- 
sistency, to  obtain  healing  within  a  fortnight  of  cases 
of  compound  fracture,  even  when  complicated  by  joint 
injury,  big  buttock  wounds  and  deep  muscle  wounds. 
We  have  excised  an  elbow-joint  full  of  pus,  and  ob- 
tained primary  healing  in  a  fortnight." 


GENERAL    SURVEY  85 

Infected  war  wounds  surfaces  may  be  swabbed  with 
brilliant  green  1 :1000  and  ke^pt  covered  with  gauze 
soaked  in  this  solution.  The  introduction  of  brilliant 
green  into  closed  cavities  is  not  recommended.  The  con- 
trol of  infection  by  brilliant  gre^Sn  is  a  relatively  slow 
process,  especially  in  infections^  associated  with  exten- 
sive inflammatory  swelling,  which  will  subside  more  rap- 
idly when  flavine  is  used.  Large  superficial  infected 
wounds  are  especially  amenable  to  brilliant  green  anti- 
sepsis, 

The  procedure  followed  by  Ligat,  in  the  case  of  sup- 
purating wounds,  consists  in  securing  adequate  drain- 
age by  free  incision,  when  necessary,  and  then  to  irri- 
gate with  a  1 :1000  solution  of  the  antiseptic  in  normal 
saline ;  finally,  the  wound  is  covered  with  gauze  soaked 
in  the  solution,  and  protective  applied  to  prevent  evapo- 
ration. Existing  cavities  are  packed  lightly  with  gauze 
soaked  in  the  solution. 

Brilliant  green  was  used  in  conjunction  with  salt 
tablets,  by  Captain  C.  H.  S.  Webb  (Brit.  Med.  Jrl.,  I, 
1917,  p.  870),  in  whose  experience  the  usefulness  of 
the  saline  pack  is  enhanced  by  the  inclusion  of  some 
antiseptic  in  the  dressing.  The  combination  of  the 
saline  pack  with  tlie  green  gave  better  results  than  the 
use  of  one  or  other  alone.  It  can  also  be  used  after 
the  method  of  Carrel — V-2  oz.  to  1  oz.  of  a  1 :1000  solu- 
tion being  S3^ringcd  down  a  tube  or  series  of  tubes 
leading  into  the  depths  of  the  w^ound.  It  is  not  so  irri- 
tant to  the  skin  edges  as  the  hypochlorite  solution. 

Preparation  of  Brilliant  Green  Ointment. — Dissolve 
brilliant  green,  8.75  gr.,  in  rectified  spirit  15  minims, 
and  incorporate  with  soft  paraffin,  2  oz.,  thereby  mak- 
ing a  1  per  cent,  ointment. 

Brilliant  Greeri  Used  as  a  Lotion. — The  brilliant 
green  is  dissolved  in  normal  saline  solution  in  the 
strength  of  1  in  1,000.  At  this  strength  it  can  be  used 
as  a  lotion,  and  gauze  soaked  in  it  can  be  applied  to 
tlie  wound  as  a  dressing.     It  is  non-irritant  to  the  tis- 


86  THE    TREATMENT    OF    FRACTURES 

sues,  while  undoubtedly  an  active  and  efficient  antisep- 
tic, and  it  acts  well  in  the  presence  of  serum. 

Methyl  Violet 

Methyl  violet  (pyoktanin),  after  having  been  found 
useful  in  veterinary  surgery,  has  been  applied  with  fa- 
vorable results  to  infected  and  suppurating  war 
wounds.  It  stains  and  destroys  the  bacteria  and  the 
necrotic  cells,  by  inducing  an  acid  reaction  and  active 
desquamation.  The  wounds  rapidly  become  clean  and 
a  frequent  change  of  dressings  is  unnecessary.  Used 
as  a  prophylactic  agent,  methyl  violet  serves  to  guard 
against  tetanus  and  other  infections  in  suspicious  war 
wounds.  TJie  method  has  the  advantage  of  simplicity 
and  cheapness. 

Magnesium  Sulphate 

The  .practice  of  Morison  and  Tulloch  (Jrl.  of  the  R. 
Army  Med.  Corps,  Vol.  XXVII,  1916,  p.  375),  in  re- 
cent wounds,  both  of  bone  and  soft  parts,  has  been  to 
swab  the  wound  freely  with  pure  carbolic  acid,  packing 
it  afterwards  for  twenty-four  hours  with  gauze  steeped 
in  carbolic  lotion  (one  in  twenty).  This,  together  with 
free  and  dependent  drainage,  has  been  frequently  suc- 
cessful in  obviating  or  minimizing  sepsis. 

This  is  followed  at  the  end  of  twenty-four  hours  by 
the  application  of  the  magnesium  sulphate  dressing, 
which  is  painless  and  easily  carried  out.  Even  in  the 
most  septic  cases  the  dressings  need  only  to  be  changed 
twice  a  day. 

Mode  of  Preparation. — A  saturated  solution  of  the 
salt  has  given  the  best  results,  both  clinically  and  ex- 
perimentally; forty  ounces  of  magnesium  sulphate  Tby 
weight)  are  dissolved  in  ten  ounces  of  glycerine  and 
boiling  water,  sufficient  to  make  a  Winchester  quart 
(by  measure).  The  glycerine  must  be  added  slowly 
while  the  solution  is  hot  and  stirred  gently  or  the  salt 


GENERAL    SURVEY  87 

precipitates  on  cooling.  The  solution  is  then  sterilized 
in  an  autoclave  and  is  ready  for  use. 

Application  as  a  Dressing. — In  recent  injuries  the 
wound  is  freely  opened  up,  any  foreign  body,  bullet, 
portion  of  shell,  clothing,  etc.,  is  removed,  and  the 
whole  wounded  surface  is  swabbed  over  with  pure  car- 
bolic acid.  In  the  case  of  fractures,  the  ends  of  the 
bone  are  treated  in  the  same  way,  and  free  fragments 
of  bone  are  removed.  The  wound  is  gently  packed  for 
twenty-four  hours  with  gauze  wrung  out  of  carbolic 
lotion  (1:20)  and  antiseptic  wool  applied  as  an  outer 
dressing.  At  the  end  of  this  time  the  wound  is  dressed, 
the  gauze  plug  is  removed,  the  wound  is  syringed  out 
with  magnesium  sulphate  solution  of  the  strength  indi- 
cated above,  no  swabbing  of  the  wound  is  done  and  the 
wound  is  loosely  packed  with  sterile  lint  taken  out  of 
the  magnesium  sulphate  solution,  in  which  it  is  con- 
stantly kept.  The  strips  of  lint  used  are  narrow  ( from 
half  inch  to  one  inch  wide),  so  that  the  solution  with 
which  they  arfe  saturated  comes  in  contact  with  all 
parts  of  the  wound  surface.  A  double  layer  of  lint, 
wet  with  the  solution,  covers  the  whole  of  the  surface 
wound.  This  is  covered  with  a  piece  of  jaconet  and 
then  cotton  wool,  the  whole  dressing  being  fixed  loosely 
by  a  bandage.  In  the  case  of  wounds  of  a  later  date, 
where  sepsis  and  suppuration  are  fully  established,  the 
treatment  by  carbolic  acid  is  omitted  and  magnesium 
sulphate  solution  is  commenced  at  once.  Dressings 
even  in  the  worst  cases  are  changed  only  at  twelve-hour 
intervals,  thus  saving  a  patient  much  discomfort  and 
trouble. 

The  effect  on  the  wound  is  very  striking.  In  two  or 
three  days  pus  has  almost  disappeared,  sloughs  begin 
to  separate,  and  the  whole  surface  presents  a  bright 
color.  The  granulations  never  become  flabby  or  cedema- 
tous,  but  instead  a  firm  vascular  healing  wound  is  seen. 
Scratching  the  surface  of  the  wound  with  a  probe 
hardly  disturbs  the  vascular  granulations.     The  growth 


88     THE    TREATMENT    OF   FRACTURES 

of  epithelium  from  the  edges  or  the  wound  proceeds 
vigorously,  and  the  treatment  may  be  continued  with 
advantage  until  the  entire  wound  is  healed.  The  re- 
sulting scar  is  firm  and  elastic  and  seldom  tends  to  con- 
tract or  to  become  painful. 

Magnesium  sulphate  solutions  are  not  recommended 
for  a  first  di^essing  for  fresh  wounds,  but  as  a  curative 
dressing  in  the  succeeding  phase  of  wound  repair. 

Vincent's  Powder 

This  boro-hypochlorite  powder  is  especially  recom- 
mended for  the  prophylactic  dressing  of  contaminated 
wounds,  and  is  considered  by  some  war  surgeons  as 
extremely  valuable  for  this  purpose.  The  antiseptic 
action  of  the  dry  dressings  is  powerful,  and  the  powder 
does  not  injure  the  body  or  the  cell,  being  free  from 
irritative,  caustic,  and  toxic  properties.  War  wounds 
are  claimed  to  heal  with  remarkable  regularity  under 
its  influence.  Employment  of  this  powder  is  both  very 
simple  and  very  cheap. 

Preparation  of  Vincent's  Poivder. — 

Desiccated  Calcium  Hypochlorite ...    10  grs. 
(Titration  of  100  to  110  liters  of 
chlorine.) 
Pulverized  Desiccated  Boric  Acid ...    90  grs, 
(Passed  through  a  moderately  fine 
sieve.) 
Pulverize  separately,    mix    with    care,    and   keep   the 
powder  in  colored  glass  bottler  closed  with  a  paraffin- 
coated  stopper. 

Technique  of  Vincent's  Method. — The  wound  is  care- 
fully cleansed,  all  contused  or  necrotic  tissues  are  cut 
away,  the  projectile  and  particles  of  clothing,  etc.,  are 
removed.  This  is  followed  by  irrigation  with  boiled 
water  under  pressure  and  accurate  hemostasis.  The 
antiseptic  powder  is  then  applied  in  all  the  recesses  of  the 


GENERAL    SURVEY  89 

wound;  carefully  exploring  the  different  layers  with  the 
grooved  catheter  in  order  to  expose  all  interstices  to 
the  action  of  the  mixture,  which  serves  at  the  same  time 
as  a  hemostatic.  The  wound  itself,  the  surrounding 
skin  and  the  first  layer  of  the  dressings  should  be  freely 
covered  with  the  powder.  Into  wound  channels  with 
narrow  openings  the  powder  can  be  introduced  by 
means  of  an  insufflator  devised  by  Vincent,  with  four 
glass  cannulas  of  different  caliber,  through  which  a 
large  amount  of  the  powder  can  be  blown  into  the 
wound.  At  tlie  end  of  forty-eight  hours  the  dressing  is 
changed  for  the  first  time,  and  again  renewed  three  or 
four  days  later.  On  account  of  the  very  profuse  wound 
secretion  which  results,  only  vestiges  of  the  antiseptic 
are  in  evidence  when  the  dressings  are  changed.  Wound 
drainage  is  not  interfered  with  in  any  way,  all  secretions 
being,  on  the  contrary,  drawn  to  the  surface.  The 
antiseptic  remains  for  many  hours  in  contact  with,  the 
wound,  a  noteworthy  feature  of  this  method,  permitting 
it  to  exert  a  continuous  disinfecting  action. 

•In  the  extensive  experience  of  Sauvage,  infected  war 
wounds  presented  a  remarkably  favorable  aspect  under 
the  influence  of  this  treatment  (La  Presse  Medicale, 
8  Nov.  1917,  p.  644),  and  Martin  (Jrl.  de  Med.  et  de 
Chir.  Prat.,  10  Nov.  1917,  p.  869)  considers  it  as  the 
antiseptic  of  choice  in  war  surgery.  After  employing 
it  in  extremely  severe  and  variegated  cases,  Sauvage 
finds  that  properly  applied  it  counteracts  in  a  remark- 
able way  the  grave  infections  which  threaten  war 
wounds  in  the  beginning  of  their  course.  The  applica- 
tion of  the  powder  must  always  be  preceded  by  careful 
surgical  preparation  of  the  wound.  In  the  vast  ma- 
jority of  cases  such  wounds  present  a  good  appearance 
and .  take  an  aseptic  course.  Should  infection  persist, 
which  is  exceptional,  it  appears  to  be  greatly  alter- 
nated, and  is  checked  by  another  application  of  the 
powder.  (Bull,  de  I'Acad.  de  :Med.,  LXXVII,  6  Nov. 
1917,  p.  548.) 


90  THE    TBEATMENT    OF   FRACTURES 

Sunlight  and  Ozone  Treatment  of  Infected  Wounds 

Heliotherapy,  or  sunlight  treatment  of  war  wounds, 
deserves  to  be  more  extensively  employed  as  a  physio- 
logical curative  method,  the  routine  adoption  of  which 
is  urged  by  Dr.  M.  Cazin  (Monograph,  Paris,  1917) 
as  a  measure  capable  in  many  cases  of  greatly  abridg- 
ing the  duration  of  the  treatment  of  war  wounds  and 
essentially  reducing  the  number  of  war  invalids.  Sun- 
light treatment,  first  recommended  by  Rollier  in  tuber- 
culosis and  traumatism,  is  most  successful  when  the 
patients  are  exposed  nude  for  many  hours  to  the  rays 
of  the  sun.  Although  total  insolation  is  always  to  be 
preferred,  local  insolation  with  a  graded  action  of  the 
sun  on  the  course  of  the  wounds  materially  assists  the 
processes  of  repair.  The  exposure  to  the  sun  must  be 
direct,  in  the  open  air,  in  order  to  improve  nutrition 
and  promote  oxydation,  and  total,  including  the  entire 
body,  the  resistance  increasing  in  proportion  to  the  ex- 
tent of  the  insolated  surface.  Insolation  of  the  clothed 
body  is  cautioned  against  as  liable  to  induce  visceral 
congestion. 

The  insolation  method  should  be  carried  out  progres- 
sively, always  beginning  with  the  less  sensitive  lower 
extremities,  also  when  the  wound  concerns  the  thorax  or 
an  upper  limb.  Observation  of  the  following  rules  is 
recommended : 

Rules  for  Use  of  Heliotherapy. — First  day:  Expose 
only  the  feet  to  the  sun,  during  fifteen  minutes,  in  three 
sessions,  separated  by  intervals  of  from  half  an  hour 
to  one  hour. 

Second  day :  Altogether  thirty  minutes  of  insolation, 
of  which  fifteen  for  the  legs,  in  three  sessions  at  half- 
hour  intervals. 

Third  day:  Exposure  of  forty-five  minutes  in  three 
sessions  of  fifteen  minutes,  of  which  five  minutes  each 
time  for  the  thighs. 

Fourth  day :  One  hour's  exposure,  in  three  sessions  of 


GENERAL    SURVEY  91 

twenty  minutes  each,  of  which  only  five  minutes  for  the 
abdomen,  always  with  an  interval  of  half  an  hour  be- 
tween the  sessions. 

Fifth  day :  Three  sessions  of  twenty-five  minutes,  of 
which  five  for  the  thorax,  making  altogether  one  hour 
and  fifteen  minutes  exposure  to  the  sun. 

The  total  duration  of  the  exposure  is  increased  by 
fifteen  minutes  daily,  adding  five  minutes  to  every  ses- 
sion for  each  of  the  segments  which  have  been  exposed 
during  the  first  five  days.  In  this  way  a  total  is  reached 
of  three  hours'  sunbath  in  three  sessions.  The  body 
must  be  sheltered  for  some  minutes  from  the  sun,  how- 
ever, until  the  appearance  of  a  brown  pigmentation 
permits  a  continuous  exposure  during  three  hours. 

After  exposure  to.  the  sun.  Dr.  Reinbold,  director 
of  the  Evian  Hospital,  where  the  method  is  extensively 
utilized,  leaves  the  wound  exposed  to  the  air  for  part 
of  the  day,  merely  covering  it  with  a  thin  layer  of 
sterile  gauze.  For  the  night,  compresses  moistened  in 
sterilized  water  are  added. 

Aside  from  the  analgesic  action  of  the  sunbath,  its, 
local  effect  promptly  induces  a  change  in  the  condition 
of  the  wound.  In  the  second  stage  of  the  treatment, 
about  the  eighth  to  tenth  day,  the  suppuration  di- 
minishes, after  having  notably  increased  following  the 
first  sessions,  and  healthy  granulation  tissue  develops ; 
the  wound  becomes  dry  and  clean,  its  borders  retract, 
and  a  zone  of  epidermization  makes  its  appearance. 
Constant  phenomena  in  the  sunlight  treatment  of 
wounds  are  regional  pigmentation,  a  change  in  the 
character  of  the  pus,  and  an  abundant  serous  exudate 
over  the  entire  surface  of  the  wound,  which  soon  dries 
up  more  or  less  completely. 

Atonic  and  indolent  wounds,  in  the  experience  of 
Cazin,  on  exposure  to  the  sun,  became  regularly  cov- 
ered with  a  layer  of  healthy  granulations,  and  in  other 
wounds,  without  an  apparent  tendency  towards  epider- 
mization,  an  epidermal  margin  promptly  appeared  at 


92     THE    TREATMENT    OF   FRACTURES 

the  borders  and  advanced  without  arrest  towards  the 
center  of  the  wound. 

Sunlight  treatment  was  found  to  hasten  recovery,  not 
only  in  wounds  of  the  extremities,  but  also  in  wounds 
of  the  thorax  and  abdomen.  Excellent  results  were 
obtained  in  infected  fractures,  and  in  several  cases  where 
the  bony  lesions  were  such  as  to  endanger  the  preserva- 
tion of  the  limb,  heliotherapy  led  to  complete  consoli- 
dation and  perfect  recovery.  Some  cases  of  infected 
fracture  of  both  leg  bones  healed  in  a  few  weeks  under 
sunlight  treatment,  after  the  condition  had  remained 
stationary  for  months,  in  spite  of  repeated  interven- 
tions and  all  other  treatments.  The  results  of  helio- 
therapy were  equally  favorable  in  joint  infections,  and 
in  the  cicatrization  of  amputation  stumps  with  bony 
fistulas. 

In  Delbet's  service,  all  wounds  are  exposed  daily  for 
as  long  as  possible  to  air  and  light,  covered  only  with 
a  fourfold  layer  of  gauze,  without  cotton  or  bandage. 
Very  remarkable  results  were  obtained  with  this  sim- 
ple treatment.  Gravely  infected  wounds  which  yielded 
a  highly  positive  pyoculture  became  transformed,  so 
that  in  two  days  the  pyoculture  became  entirely  nega- 
tive ;  in  one  instance,  the  wound  secretions  became  in 
forty-eight  hours  not  only  bactericidal  but  bacteriolytic 
for  the  vibrio.  This  simple  plan  of  wound  treatment 
is  warmly  recommended  by  Delbet  (La  Presse  Medicale, 
XXIII,  1915,  p.  237). 

Artificial  light,  in  form  of  electric  lamps,  is  always 
available,  and  in  the  experience  of  Chaput  (La  Presse 
Med.,  XXII,  1914,  p.  606)  were  found  to  be  equally 
applicable  as  sunbaths  for  local  use  in  burns  and  ulcera- 
tions. An  ordinary  electric  lighting  outfit  provides  a 
simple,  cheap,  practical,  and  highly  efficient  method  of 
treating  infected  or  gangrenous  wounds,  and  it  is  sug- 
gested that  this  mode  of  treatment  may  find  its  uses  in 
certain  Complications  of  war  wounds. 

Ozone  treatment  of  war  wounds  is  a  very  recent  in- 


GENERAL    SURVEY  93 

novation,  recommended  on  the  basis  of  satisfactory  and 
remarkable  results  by  Major  George  Stoker,  of  the 
Royal  Army  Medical  Corps  (1917).  The  necessary 
portable  apparatus  for  generating  ozone  employed  by 
him  is  known  as  Andriolis  oxonizer,  which  is  called 
into  operation  by  a  four-volt  battery  animating  a  quar- 
ter-inch sparking  RuhmkorfF  coil.  The  oxygen  passes 
from  a  cylinder  through  the  ozonizer,  and  in  doing  so 
comes  in  contact  with  a  metal  armature,  the  effect  of 
this  being  to  transform  the  oxygen  into  ozone. 

The  treatment  consists  in  the  application  of  ozone 
to  the  affected  parts.  At  first  ozone  causes  an  increase 
of  this  discharge  of  pus ;  later  on  the  pus  is  replaced 
by  clear  serum,  which  at  a  still  later  stage  becomes  red- 
dish or  pinkish.  Ozone  has  the  particular  power  of 
disclosing  dead  bone,  foreign  bodies,  septic  deposits, 
and  so  forth. 

Mode  of  Application.  —The  ozone  is  applied  on  the 
wound  surface  or  to  the  cavities  and  sinuses  for  a 
maximum  time  of  fifteen  minutes,  or  until  the  surface 
becomes  glazed.  It  is  a  strong  stimulant,  and  deter- 
mines an  increased  flow  of  blood  to  the  affected  part. 
It  is  a  gernucide,  which  destroys  all  hostile  micro- 
organic  growth. 

Acetozone 

Acetozone,  or  benzoyl-acetyl-peroxide,  has  been 
shown  to  be  a  potent  disinfectant,  and  under  its  use 
numerous  cases  of  septic  wounds  in  the  experience  of 
Gore  Gillon  healed  up  in  three  weeks,  after  having  re- 
sisted all  other  treatment  for  four  or  five  months.  It 
can  be  applied  to  deep  wounds  by  Carrel-Dakin  tubes, 
by  the  bath  method,  or  in  a  waterproof  bag,  or  by  wet 
dressings  of  10-grain  strength  solution,  renewed  two  or 
three  times  a  day. 

Mode  of  Preparation. — (1)  The  solution  must  be 
made  by  adding  5  to  7  grains  to  1  pint  sterile  water 
at  112°  F.,  left  to  stand  for  two  hours,  and  should  not 


94     THE    TREATMENT    OF    FRACTURES 

be  filtered.  (f2)  Or  a  10-grain  to  1-pint  solution  can  be 
used  with  dressings  or  Carrel-Dakin  tubes,  etc.  (3) 
In  very  septic  cases,  swarming  with  anaerobes,  etc.,  a 
20-grain  to  60-grain  solution  may  be  used.  (4)  It 
should  be  made  fresh  every  seven  days,  and  the  bottle 
shaken  before  using. 

Acetozone  may  be  used  cold  as  a  bath;  {a)  con- 
taining 5  grains  to  the  pint,  (5)  or  as  a  7-grain  solu- 
tion M^th  one-third  hot  water  added.  Its  action  is  very 
rapid ;  unhealed  amputation  stumps  heal  quickly  if  put 
into  a  bath  of  this  solution  for  half  an  hour  daily,  and 
dressed  afterwards  with  dressings  of  sterile  lint  or 
gauze  soaked  in  the  10-grain  solution.  Used  in  a  20- 
grain  solution  it  is  an  efficient  sterilizer  of  the  skin. 
(Brit.  Med.  Jrl.,  II,  1917,  p.  909.) 


Delbefs  Pyoculture  (La  Presse  Med.,  1915,  p.  239). 
— This  method  is  based  on  the  reflection  that  under 
general  and  local  conditions  so  unfavorable  as  to  pre- 
clude the  patient's  fight  against  the  infectious  microbes, 
these  would  presumably  be  extremely  numerous  and 
multiply  abundantly  in  the  wound  secretions.  Under 
better  conditions,  permitting  a  fight  against  the  infec- 
tion, the  microbes  would  grow  but  slightly,  perhaps 
less  than  in  ordinary  culture  bouillon.  Finally,  in  case 
the  body  conquers  the  infection,  the  microbes  would 
hardly  grow  at  all  in  the  wound  secretions,  and  per- 
haps be  actually  destroyed  therein.  There  would  thus 
be  three  phases,  corresponding  to  the  victory  of  the 
microbe :  the  fight  between  it  and  the  body  forces :  the 
victory  of  the  patient.  This  theory  was  borne  out  by 
practical  experience. 

Technique  of  Pyoculture. — A  little  pus  is  removed 
from  the  wound  in  the  customary  manner,  and,  with  the 
contents  of  the  pipette,  a  smear  preparation  and  an  in- 
oculation of  peptonized  bouillon  are  made.  The  closed 
pipette  and  the  inoculated  test  tube  are  then  placed  in 


GENERAL    SURVEY  95 

the  incubator,  and  24  hours   later  specimens  are  pre- 
pared from  the  contents. 

A  comparative  study  of  these  three  preparations  fur- 
nishes   valuable    information   concerning   the    progress 
and  the  operative  indications.     The  pyocultural  findings 
supplement  the  findings  in  the  first  specimen,  prepared 
immediately   after   the    removal   of   the   pus    from    the 
wound.     The  pyoculture  is  positive  when  the  microbes 
are  seen  to  multiply  abundantly  in  the  pus ;  an  active 
bacterial    growth,    especially    when    more    abundant   in 
the  pus  than  in  the  bouillon,  has   a  serious  prognosis 
and  calls  for  surgical  interference.     In  other  cases  the 
microbes  do  not  develop  in  the  pus,  but  grow  well  in 
the  bouillon;  this  means  that  the  pyoculture  is  zero  and 
indicates  an  efficient  fight  on  the  part  of  the  patient. 
This  fight  should  be  assisted  but  not  hindered  by  thera- 
peutic measures.     In  the  last  group  of  cases,  the  pyo- 
culture   is    negative ;    the   number    of   microbes    in    the 
pipette  not  only  does  not  increase,  but  it  actually  di- 
minishes, indicating  that  the  wound  secretions  are  not 
only   bactericidal   but   bacteriolytic.      The   patient    re- 
covers through  a  process  of  autovaccination ;  and  it  is 
advisable  to  leave  well  enough  alone,  as  this  fortunate 
outcome  could  onl}*  be  impeded  by  treatment. 

Vaccine  and  Serum  Treatment  of  Infected  Wounds 

The  fundamental  principle  of  vaccine  therapy,  ac- 
cording to  a  definition  by  Sir  Almroth  Wright,  is  to 
exploit,  in  the  interest  of  the  infected  tissues,  the  un- 
exercised immunizing  capacities  of  the  uninfected  tis- 
sues. 

Vaccine  therapy,  judiciously  employed,  offers  the 
following  advantages : 

(1)  Increase  of  the  general  resistance.  (2)  Limita- 
tion of  bacterial  invasion  to  the  immediate  wound  sur- 
roundings. (3)  Heightened  and  hastened  regeneration 
of  tissues  in  the  damaged  territory 


96     THE    TREATMENT    OF    FRACTURES 

The  following  routine  treatment  is  suggested  by 
Kenneth  Goodby  (Lancet,  II,  1916,  p.  585)  as  a  result 
of  his  investigation^ :  Polyvalent  vaccines  should  be  pre- 
pared from  stains  of  organisms  isolated  from  the  in- 
fected wounds,  consisting  of  (1)  streptococci  (aerobic 
and  anaerobic  varieties),  sensitized  with  antistreptococ- 
cal  serum;  (2)  B.  proteus ;  (3)  B.  lactis  aerogenes ; 
and  (4)  B.  coH. 

A  mixed  vaccine  of  sensitized  polyvalent  streptococ- 
cus 5,000,000,  with  B.  proteus  10,000,000,  should  be 
given  to  all  septic  cases  when  admitted,  pending  the 
bacteriological  report.  In  cases  of  gas  gangrene,  strep- 
tococcal vaccine  combined  with  B.  proteus  and  B.  lactis 
aerogenes  should  be  used  in  strength  of  10,000,000 
each.  The  inoculations  as' indicated  by  the  bacterio- 
logical examination  should  be  repeated  on  the  third 
day,  and  the  dose  raised  to  10,000,000  streptococcus 
with  20,000,000  of  the  appropriate  bacilli.  Mean- 
w^hile,  autogenous  vaccine  may.  if  necessary,  be  pre- 
pared for  special  cases  when  desirable;  otherwise  the 
appropriate  polyvalent  vaccine  may  be  continued  as 
determined  by  the  bacteriological  indications. 

Serum  Treatment  of  Leclainche  and  Vallee  (Bull,  de 
I'Acad.  de  Med.,  1915,  p.  280). — On  the  basis  of  ex- 
perimental investigations,  it  was  shown  that  tlie  bac- 
terial agents  in  wounds  can  be  made  to  undergo  diges- 
tion, by  sensitizing  the  organic  cells  with  a  septic 
serum,  the  cells  retaining  their  full  vitality  and  ca- 
pacity to  build  up  repair  tissue.  The  polyvalent  serum 
of  the  French  investigators  contains  the  antibodies  cor- 
responding to  the  agents  of  the  various  inflammations 
and  suppurations,  represented  by  several  varieties  of 
staphylococci  and  streptococci,  coli  bacilli,  pyocyaneus, 
proteus.  To  these  aerobic  germs  they  added  several 
types  of  anaerobes,  the  perfringens  and  septic  vibrio. 
The  polyvalent  serum  is  obtained  from  horses  which 
have  been  immunized  against  the  germs  of  the  different 
suppurations.      It   was    originally   intended   for   purely 


GENERAL    SURVEY  97 

local  use  as  a  direct  application  to  infected  wounds, 
in  fo.rni  of  injections  or  dressings;  but  it  has  also  been 
successfully  employed  in  hypodermic  or  intravenous 
injections,  in  certain  cases  of  staphylococcus  and  strep- 
tococcus septlc.Tmia.  Cazin  (Paris  Medical,  XI,  1916, 
p.  262),  in  a  series  of  observations,  noted  excellent 
eflf'ects  of  the  polyvalent  serum  on  infected  wounds, 
more  particularly  streptococcus  infections,  and  recom- 
mends it  not  only  for  its  local  action,  when  used  in 
Avound  dressings,  but  also  for  its  general  action  in  sep- 
ticjemia,  when  hypodermic  injections  are  applied  out- 
side the  scat  of  the  lesions.  No  serum  reaction  was 
observed  to  follow  on  direct  application  of  the  serum 
to  the  wounds  in  fairly  large  and  frequently  repeated 
doses.  Unless  improvement  is  promptly  manifested, 
there  is  no  advantage  in  continuing  this  treatment. 

A  large  number  of  septic  cases  under  the  care  of 
R.  H.  Jocelyn  Swan  (Lancet,  II,  1916,  p.  859)  were 
treated  as  a  routine  measure  with  a  mixed  polyvalent 
vaccine  of  proteus  and  streptococcus,  with  highly  sat- 
isfactory results.  Appropriate  combinations  to  suit  a 
given  case  are  administered  later  on,  according  to  the 
findings  on  exarjiination  of  the  wound  conditions.  He 
is  convinced  of  the  great  use  of  vaccines  as  a  supple- 
mentary treatment  to  surgical  measures  in  septic 
wounds,  and  is  satisfied  that  the  routine  employment  of 
a  polyvalent  vaccine  of  proteus  and  streptococcus  is  of 
value  in  inhibiting  the  tissue  necrosis  caused  b}^  anaero- 
bic bacilli,  which  are  so  commonly  associated  with  these 
organisms  in  gunshot-wound   infection. 

"I  have  found  the  greatest  value  of  vaccine  therapy 
in  the  treatment  of  complicated  septic  fractures  of  long 
bones  and  of  fractures  which  open  into  joint  cavities. 
In  the  treatment  of  septic  compound  fractures  I  now 
make  a  routine  practise  of  giving  a  preliminary  dose  of 
polyvalent  vaccine  (proteus  and  mixed  streptococci), 
and  then  after  two  or  three  days  freely  open  the  wound 
to   secure  adequate  drainage,   approximating  the   frag- 


98  THE    TREATMENT    OF    FRACTURES 

ments  and  only  removing  those  fragments  which  are 
undoubtedly  completely  separated,  at  the  same  time 
taking  advantage  of  the  opening  of  the  vi^ound  to  obtain 
further  bacteriological  examination.  Extension  appa- 
ratus of  various  types  of  splints  suitable  to  the  indi- 
vidual fracture  are  applied,  but  should  the  resulting 
position  of  the  fragments  prove  on  further  radio- 
graphic examination  to  be  unsatisfactory,  I  have  no 
hesitation,  after  a  further  few  doses  of  specific  vaccine, 
in  securing  the  bone  fragments  in  apposition  by  means 
of  silver  wire  or  even  bone  plates  in  the  presence  of 
sepsis,  and  can  now  look  back  on  a  series  of  cases  in 
which  not  only  have  limbs  been  saved,  but  bones  in  good 
alignment  and  functional  use.  Further,  the  result  as 
regards  sinus  formation  and  necrosis  of  fragments  of 
bone  in  the  seat  of  fracture  have  been  more  appreciably 
lessened  in  those  cases  in  which  vaccines  have  been  used 
than  in  those  in  which  exactly  similar  surgical  measures 
were  employed  without  the  assistance  of  vaccines." 

Antiseptic  vaccines  have  proved  especially  useful  in 
the  safeguarding  of  tissue  adjacent  to  an  injected 
wound  against  bacterial  invasion.  Excellent  results 
have  also  followed  their  employment  as  adjuvants  to  a 
well-established  and  efficient  physiological  drainage. 

Technic  of  Wound  Dressings  with  Polyvalent  Serum. 
— The  employment  of  this  method  excludes  the  use  of 
all  antiseptic  agents,  as  these  without  exception  inter- 
fere with  the  phagocytic  and  opsonizing  action  of  the 
serum.  The  wounds  should  therefore  first  be  washed 
with  a  lukewarm  boiled  solution  of  sodium  chloride, 
nine  parts  in  a  thousand  parts  of  water,  preferably 
distilled  water.  According  to  the  cases,  layers  of  steril- 
ized gauze  soaked  in  the  serum  are  applied  to  the  wound, 
or  serum-soaked  strips  of  gauze  are  introduced  into 
fistulus  tracts  and  deep  cavities.  Undiluted  serum  may 
be  injected  into  the  wound  channels,  if  preferred.  A 
dry  protective  dressing  is  then  applied.  The  scrum 
dressings   are  removed   according  to   requirements   in   a 


aENERAL    SURVEY  99 

given  case,  usually  in  the  morning  and  at  night.  Pro- 
longed use  of  the  polyvalent  serum  in  form  of  wound 
dressings  involves  no  danger  of  anaphylaxis  or  other 
complications. 

Polyvalent  Serum  in  Hypodermic  and  Intravenous 
Injections. — Although  the  use  of  polyvalent  serum  in 
wound  dressings  is  safe  in  all  cases,  injections  may  give 
rise  to  sj^mptoms  of  anaphylaxis  in  patients  who  have 
previously  received  a  preventive  injection  of  antitetanic 
serum.  As  a  precautionary  measure  in  such  cases,  2 
c.c.  of  the  polyvalent  serum  should  first  be  injected 
under  the  skin,  guarding  against  penetration  of  the 
needle  into  a  vessel ;  at  the  end  of  eight  to  ten  hours, 
in  the  absence  of  symptoms,  an  injection  of  about  20  c.c. 
may  be  applied.  For  the  intravenous  use  of  the  serum, 
the  patient  is  prepared  b}'^  a  preliminary  very  slow  in- 
jection of  ten  drops  of  diluted  serum,  1  part,  in  phys- 
iological solution,  10  parts.  At  the  end  of  a  quarter  of 
an  hour  the  serum  is  injected  very  slowly  in  progressive 
fractional  doses  (two  drops,  one-quarter  c.c,  one-half 
c.c,  one  c.c,  two  c.c.)^  carefully  observing  the  patient's 
reaction  and  injecting  ether,  if  necessary. 

Precautions. — Serum  flasks  which  have  been  opened 
should  be  utilized  at  once. 

Preparation  of  Autopyovacc'me,  of  Weinberg  and 
Seguin  (Seances  et  Mem.  d.  1.  Soc  de  Biol.,  Vol.  79, 
1916,  p.  2). — The  required  time  is  only  one  to  two 
hours.  A  small  quantity  of  pus  or  serum  from  the 
wound  is  placed  in  contact  with  Lugol's  solution  (one- 
third  diluted  with  distilled  water)  during  ten  to  thirty 
minutes,  the  mixture  is  then  centrifugated,  the  sediment 
is  freed  from  its  liquid  portion,  and  taken  up  with  a  few 
cc  of  physiological  salt  solution.  Contact  with  the 
iodated  solution  is  lengthened  (twenty  to  thirty  minutes) 
when  the  wounds  contain  sporulated  elements. 

Microbes  treated  in  this  manner,  including  the  spores., 
are  not  only  rendered  inocuous,  but  almost  invariably 
destroyed. 


100   THE    TREATMENT    OF    FRACTURES 

'I'he  injections  often  produce  a  sudden  improvement 
of  the  general  condition  and  a  diminution  of  the  oedema 
in  the  wound  surroundings.  Sixteen  wounded  soldiers, 
under  the  observation  of  Delbet,  including  five  cases  of 
gas  phlegmon  and  gas  gangene,  were  treated  with  very 
beneficial  results.  The  real  value  of  this  and  other 
autovaccines  remq.ins  to  be  tested  on  a  more  extensive 
scale. 

Donaldson's  Method  (Introduction  of  Living 
Anaerobes) 

A  method  of  wound  treatment  by  the  introduction  of 
living  cultures  of  a  spore-bearing  anaerobe  of  the  pro- 
teolytic group  has  been  suggested  in  the  last  few 
months  by  Donaldson  and  Joyce  (Lancet,  II,  1917,  p. 
445).  Using  the  salt  pack  method,  with  good  results, 
they  made  the  clinical  observation  that  cases  that  smell 
(the  odor  being  one  of  the  most  characteristic  features 
of  these  cases)  do  Well,  while  those  which  do  not  smell 
make  no  headw^ay.  Bacteriologically,  a  certain  bacillus 
was  found  to  be  apparently  constant  in  the  wounds 
M'hich  emit  the  odor,  while  it  is  absent  or  cannot  be  re- 
covered from  those  which  do  not  smell.  This  bacillus 
is  a  spore-bearing  anaerobe  of  a  saprophytic  nature, 
and  belongs  to  the  proteolytic  group  of  organisms.  It 
acts,  apparently  in  virtue  of  its  proteolytic  powers, 
only  on  devitalized  tissue,  and  possibly  on  toxalbumens, 
and  appears  to  possess  no  power  of  attacking  healthy 
structures.  Its  functions  are  directed  towards  the  re- 
moval not  only  of  the  grossly  damaged  tissue,  but  it 
succeeds  also  in  attacking  the  microscopically  damaged 
structures.  As  a  result,  the  body  forces  are  freed  from 
the  constantly  expected  menace  of  septic  poisoning,  thus 
allowing  them  to  begin  the  work  of  repair.  The  au- 
thors give  examples  of  gunshot-wound  cases  which  had 
been  treated  in  various  ways  previously,  including  the 
salt  pack  method,  but  without  success.  "These,  how- 
ever, on   being  sown   later  with   living  cultures   of  the 


GENERAL    SURVEY  101 

bacillus,  have  immediately  started  to  do  well,  and  have 
ended  in  rapid  recovery." 

It  is  too  early  to  comment  upon  this  new  departure, 
beyond  pointing  out  that  it  is  an  added  argument  in 
favor  of  the  growing  conviction  that  the  presence  of 
devitalized  tissue  in  a  wound  represents  the  real  danger 
element  of  wound-infections. 


CHAPTER   U 
WOUNDS  AND  FRACTURES  OF  THE  SHOULDER 

I.  Anatomical  Types   and   Clinical   Course 

It  is  sometimes  very  difficult  to  be  sure  that  the  joint 
is  involved  when  a  missile  has  traversed  the  shoulder : 
the  thick  muscular  covering  in  powerful  men,  the 
diffuse  pain,  the  swelling  due  to  effusion  of  blood 
which  often  is  extreme,  the  frequent  coincidence  of 
injury  to  the  lung,  especially  in  soldiers  hit  in  the 
left  shoulder,  are  factors  that  may  render  the  diagnosis 
anything  but  easy  when  the  bony  injury  is  not  exten- 
sive. It  is  well  to  be  forewarned  of  this,  for  mistakes 
are  common. 

It  should  be  borne  in  mind  that  if  a  radiograph  is 
not  obtainable  it  is  better  to  diagnose  a  fracture  that 
does  not  exist,  than  to  overlook  a  joint  injury  which 
will  manifest  itself  all  of  a  sudden  by  grave  complica- 
tions. I  lay  special  stress  upon  this  point,  for  I  have 
twice  received  in  my  ambulance  at  the  front  men 
hit  in  the  lung  for  immediate  incision  of  the  pleura 
in  whom  the  septic  conditions  were  really  entirely  due 
to  an  arthritis  of  the  shoulder.  Immediate  exploratory 
incision  showed  that  the  bullet  before  entering  the 
thorax  had  ground  fragments  of  clothing  into  the  head 
of  the  humerus,  and  that  this  was  the  cause  of  the 
infection. 

Four  prominent  anatomical  types  are  observed  in 
injuries  of  the  shoulder. 

The  crush- fracture  {fracture    parcellaire).- — This  is  a 

102 


THE  SHOULDER 


103 


crushing  of  the  trabeculae  of  the  cancellous  tissue 
after  fracture  of  the  cartilage,  or  the  compact  shell  of 
the  head,  with  or  without  a  shrapnel  ball,  splinter  of 
shell  or  grenade  in  situ. 

A  fracture  limited  to  the  head. — A  furrow  or  groove 
at  the  level  of  the  anatomi- 
cal neck,  or  a  tunnel  through 
the  cancellous  tissue,  with 
or  without  radiating  fissures, 
but  without  detachment  of 
the  head.  This  is  more 
often  the  result  of  long- 
range  bullets,  and  in  these 
cases  complications  do  not 
usually  develop. 

Complete  separation  of  the 
head  along  a  line  which  may 
correspond  to  the  line  of  the 
epiphysial  cartilage,  which 
is  still  present  in  young 
soldiers,  since  it  rarely  dis- 
appears before  twenty-two 
yeafs  of  age. 

Complete  destruction  of  the 
upper  end  of  the  humerus,  a 
very  frequent  injury,  indeed 
the  most  frequent  of  all, 
produced  either  by  a  short- 
range  bullet  or  by  a  splinter 
of  shell  or  grenade.  In 
these  cases  it  is  not  unusual 
to.  find  the  whole  of  the 
upper    end     of     the     bone 

smashed  to  atoms.  The  bone-dust  and  sphnters 
are  driven  into  the  muscles  which  are  crushed,  lacer- 
ated, and  contused,  and  in  a  few  hours  become  the  seat 
of  formidable  septic  phenomena  which  develop  with 
great  rapidity.     These  injuries  may  exist  alone  or  in 


Fig.  lU. — The  projectile  i« 
embedded  in  the  head  of  the 
humerus  svirromided  by  a  j^ro- 
gressive  osteitis.  The  radio- 
graph was  taken  fifteen  days 
after  the  injury.  Subsequent 
removal  with  localised  sul:)- 
cartilaginous  cleaning  out  of 
the  head  of  the  bone  has  pro- 
duced a  good  result,  but  the 
movements  of  the  joint  are 
limited  by  adhesions.  An 
operation  immediately  after 
the  injviry  would  have  given 
a  better  restoration  of  func- 
tion. 


104    THE   TREATMKN.T  OF  FRACTURES 

conjunction  with  other  fractures  of  adjacent  parts, 
such  as  fracture  of  the  coraco-acromial  arch,  of  the 
glenoid  cavity,  and  of  the  scapula. 

What  is  the  course  of  these  different  types  ? 

The  crush-fractures,  with  the  projectile  remaining  in 
the  head  of  the  bone,  are  sometimes  mild  in  their 
course  when  they  are  due  to  a  bullet  or  a  shrapnel 
ball,  but  one  often  sees  progressive  osteitis  occur  around 
the  projectile,  or  oedema  of  the  shoulder  signifying 
deep  infection,  and  sometimes  a  late  suppurative 
arthritis.  Complications  are  the  rule  if  the  injury 
is  due  to  a  shell-splinter. 

The  crush-fractures  aiid  the  fractures  limited  to  the 
head  may  run  an  aseptic  course  and  behave  like  simple 
fractures  when  they  are  produced  by  long-range 
bullets  which  have  perforated  the  shoulder  like  a 
trocar,  through  punctiform  skin  openings. 

But  in  all  the  other  cases  and  invariably  when  the 
wounds  are  made  by  splinters  of  shell  or  grenade, 
however  small  the  wound  of  entry  may  be,  osteo- 
articular  infection  is  the  rule  ;  one  should  always  be 
on  the  look-out  for  it  because  ,of  its  great  frequency. 
The  few  cases  which  progress  without  grave  symptoms 
are  very  similar  at  first  to  those  which  are  followed 
by  gas  gangrene. 

Often,  especially  when  there  is  destruction  of  the 
head  of  the  bone  by  a  bullet  or  shell-splinter,  infection 
follows  with  extreme  rapidity  ;  in  a  few  hours  the 
temperature  reaches  40°  C.  (104°  F.) ;  the  general  con- 
dition becomes  grave,  the  complexion  waxy,  the  lips 
pale  and  the  cheeks  flushed  ;  the  shoulder  is  swollen 
and  globular  ;  the  ^igns  are  those  of  an  acute  diffuse 
cellulitis  ;  the  least  movement  makes  the  patient  cry 
out.  The  same  evening  or  on  the  next  day  there  is 
gas  in  the  tissues,  the  appearance  of  the  patient  is 
that  of  a  man  profoundly  toxic,  and,  unless  active 
intervention  is  practised,  death  quickly  ensues. 

This  is  the  usual  course  of  about  a  third  of  the  cases- 


THE   ^SHOULDER  105 

at  the  front  unless  immediate  action  is  taken.  More 
frequently  the  symptoms  are  less  acute,  the  infection 
is  slower ;  the  shoulder  slowly  swells  up,  the  flat 
surfaces  are  effaced,  hollows  disappear,  the  whole 
region  is  painful,  and  from  the  swollen  lips  of  the 
wounds  there  exudes  a  foetid  sero-purulent  discharge. 
Sinuses  occur  on  all  sides,  but  especially  in  front  along 
the  biceps,  and  in  the  axilla.  Unless  appropriate  treat- 
ment of  the  bony  lesion  is  carried  out,  the  patient 
wastes,  becomes  cachectic,  and  slowly  dies  of  amyloid 
degeneration,  if  disarticulation  is  not  performed.  A 
small  number  of  cases  get  well  spontaneously  with 
ankylosis  and  sinuses. 

Results  such  as  these  of  fractures  of  the  shoulder 
left  to  themselves,  can  be  avoided  ;  they  ought  no 
longer  to  be  seen.  A  wound  of  the  shoulder  correctly 
treated  from  the  start  ought  not  to  suppurate,  and 
should  get  well  quickly. 


II.  Primary  Therapeutic  Indications 

1.  Simple  Immobilisation. — ^This  is  only  suited  to 
very  mild  cases,  that  is  to  say  to  bullet  woilnds  with 
punctiform  openings.  These  wounds  do  not  suppurate 
and  the  cases  behave  like  simple  fractures.  The  only 
indication  in  them  is  to  apply  an  aseptic  dressing  and 
strictly  immobilise  the  joint  in  a  plaster  casing  made 
in  the  manner  described  farther  on.  If  the  cases  are 
numerous,  one  would  apply  a  wire  splint  suspended 
from  the  top  by  means  of  a  shng  over  the  opposite 
shoulder.  Immobilisation  should  be  kept  up  for  three 
weeks,  so  that  thehsematoma  can  be  absorbed  without 
injudicious  interference,  after  which  some  cautious 
attempts  at  movement  should  be  made,  and  the  arm 
placed  in  a  sling.  Generally,  consoHdation  is  rapid, 
but  ankylosis  is  the  rule.  If  radiography  shows  much 
damage  to  the  bone,  it  will  be  well  to  apply  continuous 


106     THE   TREATMENT   OF   FRACTURES 

extension  and  treat  the  injury  as  if  it  were  a  fracture 
of  the  shaft. 

2.  ESQUILLECTOMY  AND  SUB-PERIOSTEAL  RESEC- 
TION.— ^A  hmited  bone  operation  is  necessary  in  all 
cases  of  medium  severity,  that  is  to  say  in  the  more 
or  less  extensive  fractures  of  the  head  of  the  humerus  ; 
esquillectomy  is  suitable  for  the  smallest  injuries, 
resection  for  the  others,  which  form  the  majority. 

Let  us  take  an  apparently  simple  case.  A  small 
shell-splinter  has  traversed  the  shoulder  from  before 
backwards  and  a  fracture  is  manifest ;  as  yet  there 
is  clinically  no  infection,  and  the  wound  is  only  of  a 
few  hours'  duration.  One  is  tempted  to  say,  "No 
intervention,  simple  immobilisation  :  if  symptoms  of 
infection  appear,  there  will  always  be  time  to  make 
an  incision."  This  easy-going  optimism  appears  all 
the  more  justified  because  at  the  shoulder  a  flail  joint, 
due  to  loss  of  bone  is  very  crippling,  especially  if  the 
muscles  are  destroyed  :  ankylosis  is  better  than  a 
flail-arm,  and  one  can  understand  the  desire  to  wait 
until  one  is  forced  to  intervene.  No  one  has  the  right 
to  do  this  :  the  risks  of  waiting  are  too  great  to  allow 
one  to  expose  the  patient  to  them  by  speculating 
upon  the  chances  of  a  natural  cure.  The  uncertainty 
of  delay,  the  impossibility  of  knowing  whether  urgent 
evacuation  will  become  necessary,  the  ever-present 
menace  of  infective  complications  whose  severity  it  is 
beyond  one's  power  to  foresee,  our  absolute  ignor- 
ance of  what  the  missile  has  implanted  in  its  passage 
through  the  bone  or  the  joint,  taken  together,  impose 
upon  us  the  duty  of  making  an  early  intervention 
in  all  cases  except  the  punctiform  bullet  wound,  in 
order  to  expose  the  damaged  bone  and  clean  it. 

The  advantages  of  this  method  of  procedure  are 
the  following  : 

Complete  suppression  of  severe  primary  septic  phe- 
nomena (gas  gangrene,  septicaemia,  acute  articular 
osteitis),   which  carry  off  a  large  number  of  patients. 


THE   SHOULDER  107 

By  practising  primary  clearing  of  the  bone  lesion 
by  esquillectomy  or  resection,  I  have  not  lost  a  single 
case  of  injury  to  the  shoulder. 

Avoidance  of  early  secondary  disarticulations,  which 
are  numerous  in  the  ambulances  when  the  wounded 
arrive  late,  or  in  which  immediate  systematic  opera- 
tion is  not  the  rule.  Two-thirds  of  these  could  have 
been  avoided  by  primary  resection.  Personally,-  I 
have  only  done  one  disarticulation  of  the  shoulder 
in  twenty  months  of  war. 

Progress  that  is  entirely  or  almost  entirely  aseptic 
from  the  clinical  point  of  vieiv,  without  suppuration 
of  the  articular  lesion,  with  rapid  cure  and  preserva- 
tion of  the  functions  of  the  muscles. 

If  the  operation  is  correctly  done,  that  is  to  say 
rigidly  sub-periosteally,  if  the  muscles  are  sound,  if 
the  circumflex  is  not  severed,  and  if  the  bony  damage 
is  not  too  extensive,  the  prognosis  as  to  function  is 
ordinarily  good,  often  excellent,  rarely  bad.  On  the 
other  hand,  many  patients  who  get  well  with  ankylosis 
suffer  from  some  degree  of  osteitis,  have  sinuses,  and 
are  exposed  to  recurrent  attacks  of  infection.  I.  have 
lately  seen  a  soldier  wounded  by  a  bullet  fourteen 
months  ago  who  recovered  with  incomplete  ankylosis 
after  repeated  drainages,  and  who  got  a  chill  and  was 
suddenly  seized  with  a  very  acute  attack  of  epiphysial 
osteomyelitis  with  extensive  suppuration  on  the  eve 
of  setting  out  for  a  colony  where  his  business  interests 
lay.  Systematic  abstention  from  early  operative 
interference  entails  terrible  future  risks.  That  is  why 
we  should  bear  in  mind  the  possible  future  of  our 
patients,  and  endeavour  to  minimise  the  risk  of  sup- 
puration in  any  joint. 

What  practical  steps  should  be  taken  ? 

As  soon  as  possible  the  wound  should  be  explored, 
the  wounds  of  entry  and  exit  laid  open,  torn  muscular 
debris  clipped  away,  and  particles  of  clothing  and 
foreign  bodies  sought  for.     When  this  has  been  done, 


108     THE   TREATMENT  OF  FBACTUBES 

the  joint  is  freely  exposed  and  the  seat  of  fracture 
methodically  examined  by  enlarging  the  opening  made 
by  the  projectile. 

(a)  If  the  fracture  is  incomplete  and  the  missile 
is  embedded  in  the  bone,  the  damaged  area  of  bone 
should  be  cleared  out  with  a  curette  and  anything 
removed  that  appears  suspicious.  These  sub-car- 
tilaginous  operations  give  excellent  results.       After 


Fig.  11. — Simple  fracture  of 
the  head  of  the  humerus  by 
shell-splinter.  Separation  of  the 
head  of  the  bone  was  treated  Ijy 
early  resection  by  the  classical 
incisions,  in  spite  of  the  wound 
of  entry  being  posterior. 


Fig.  12. — Result  at  the  end 
of  two  months,  when  the  wound 
had  completely  healed  without 
suppuration.  The  patient  has 
recovered  full  movement  of  the 
joint. 


the  missile  has  been  removed,  nothing  further  is  re- 
quired than  to  plug  the  wound  loosely  with  aseptic 
gauze. 

(&)  If  the  fracture  is  very  small  and  only  involves 
part  of  the  head  of  the  humerus,  simple  esquillectomy 
will  sufHce  ;  any  loose  cartilage  is  removed  and  the 
wound  is  plugged  hghtly  and  left  open.  It  goes  with- 
out saying  that  all  foreign  bodies  and  debris  of  clothing 
on  the  surface  of  the  bone  are  carefully  sought  for, 


THE   SHOlJLDhJR  109 

and  that  any  projecting  points  are  chiselled  away  ; 
no  attention  need  be  paid  to  vertical  fissures,  which 
will  remain  aseptic  if  the  principal  area  of  damage  is 
cleared  out.  The  same  line  of  treatment  will  be  pur- 
sued if  the  head  of  the  bone  has  been  split  vertically  ; 
the  part  continuous  with  the  shaft  will  be  left  after 
trimming  it  up  with  cutting  forceps  so  as  to  adapt  it 
to  the  glenoid  cavity. 

(c)  If  the  injury  is  more  extensive  and  there  is  a 
complete  fracture  with  numerous  fragments,  and 
fissures  extending  into  the  shaft,  it  will  be  necessary 
to  leave  the  orifice  of  entrance  made  by  the  pro- 
jectile after  cleaning  it  thoroughly,  and  to  open  the 
joint  by  the  classical  incision  for  resection  along 
the  inner  border  of  the  deltoid,  incise  the  capsulo- 
periosteal  sheath  outside  the  bicipital  groove,  and 
separate  the  periosteum  with  the  rugine  in  the  direc- 
tion of  the  bony  injury.  If  the  head  is  free  in  the 
cavity  of  the  joint,  it  should  be  removed  and  the  joint 
cavity  cleared  of  all  fragments  ;  if  the  head  of  the 
bone  is  comminuted,  the  humerus  should  be  sawn 
through  at  the  level  of  the  anatomical  neck  and  the 
fracture  a  little  obliquely  downwards,  and  this  will 
be  a  very  good  section  if  the  insertion  of  the  capsule 
has  been  carefully  preserved.  After  this  has  been  done, 
a  posterior  counter-opening  for  drainage  is  made, 
enlarging  the  wound  made  by  the  projectile  if  it  is 
conveniently  situated,  or  making  a  fresh  opening 
in  a  suitable  spot  when  there  is  no  posterior  wound,  as 
will  be  described  later  on. 

3.  Extensive  Resection. — ^At  the  shoulder  the 
explosive  effects  of  a  short-range  bullet,  or  fragment 
of  shell  or  grenade,  are  often  very  marked,  and  the 
whole  of  the  upper  end  of  the  humerus  may  be  smashed 
up.  The  muscular  damage  is  considerable,  and  the 
injury  to  the  bone  affects  both  head  and  shaft, 
the  upper  third  of  the  humerus  being  destroyed  and 
reduced  to  spHnters  which  are  driven  into  the  muscles. 


110    THE   TREATMENT  OF  FBACTUEES 

The  least  delay  in  operating  allows  the  rapid  develop- 
ment of  infection. 

A  good  number  of  these  injuries  have  been  success- 
fully treated  by  disarticulation  at  the  shoulder-joint. 
On  one  day  in  a  neighbouring  ambulance  I  saw  six 
disarticulations  which  had  all  been  performed  during 
the  same  week  for  fractures  of  this  kind.  Yet  when- 
ever the  vessels  and  nerves  of  the  arm  are  intact  one 
may  try  to  save  both  life  and  limb,  even  to  the  extent 
of  actually  removing .  the  entire  upper  half  of  the 
humerus.  This  procedure  is  at  present  in  rather  bad 
odour,  because  in  the  early  days  of  the  war  many 
inexperienced  surgeons  performed  esquillectomies  that 
were  too  extensive  and  perfectly  useless,  and  through 
ignorance  caused  terrible  mutilations.  But  the  cases 
under  discussion  do  not  come  into  this  category.  In 
them  we  have  to  choose  between  an  extensive  removal 
of  bone  in  order  to  preserve  the  hand  and  its  move- 
ments, and  disarticulation  at  the  shoulder :  the  former 
operation  is,  then,  one  that  cannot  be  too  highly  recom- 
mended. Indeed  the  opening  up  of  this  enormous 
damaged  area  stops  infective  complications,  especially 
if  it  is  immediately  followed  up  by  regular  sunlight 
baths  ;  after  a  longer  or  shorter  period  of  very  localised 
suppuration,  which  the  sunlight  shortens  remarkably, 
repair  occurs  rapidly  and  uneventfully,  and  the  patient, 
if  care  is  taken  of  his  muscles,  recovers  with  a  useful 
flail-arm,  a  normal  hand,  and  very  mobile  fingers  which 
are  certainly  more  useful  than  even  the  best  artificial 
limb  after  disarticulation.  Doubt  has  been  cast  upon 
the  usefulness  of  this  "  deossified  "  limb.  But  it  is  none 
the  less  certain.  In  peace-time  one  was  able  to  study 
the  functional  value  of  cases  of  total  removal  of  the 
humerus  ;  the  results  were  so  satisfactory  that  during 
recent  years  extensive  or  total  removal  of  the  humerus 
was  advised  for  neoplasms.  "  Deossification,"  there- 
fore, is  quite  legitimate  in  military  surgery  for  the 
very  severe  cases  which  are  met  with  there.     I  per- 


THE   SHOULDER  111 

sonally  have  practised  it  many  times,  and  I  was  able 
to  show  the  8ociete  de  Chirurgie  a  patient  who  had 
lost  more  than  six  inches  of  the  humerus,  and 
further  had  had  a  resection  of  the  upper  ends  of  the  bones 
of  the  forearm  done  on  the  same  side,  and  yet  enjoyed 
considerable  useful  movement.  The  operation  should 
be  done  as  far  as  possible  with  the  rugine,  with  as  littl© 
periosteal  damage  as  can  be  managed.  One  can 
hardly  expect  from  these  measures  a  bony  column 
sufficiently  firm  to  unite  the  part  which  remains  with 
the  glenoid  cavity,  but  the  muscles  are  mOre  completely 
preserved,  and  their  contraction  will  eventually 
greatly  improve  the  future  condition  of  the  wounded 
whom  we  are  all  so  anxious  to  save. 

It  is  the  rule  that  in  cases  of  fracture  where  dis- 
articulation appears  necessary,  but  where  integrity  of 
the  vessels  and  nerves  leads  one  to  hope  for  a  useful 
hand,  the  surgeon  should  do  a  primary  resection  with- 
out being  deterred  by  the  fear  of  too  extensive  sacrifice 
of  bone.  This  method  always  succeeds  in  preventing 
or  minimising  septic  complications. 

To  sum  up,  we  may  say  that,  putting  aside  gunshot 
wounds  with  punctiform  skin  openings,  one  should 
practise  the  following  primary  operations  for  all 
wounds    of    the    shoulder : 

For  crush  fractures,  removal  of  fragments  and 
curettage. 

For  limited  fractures,  sub-periosteal  resection. 

For  destruction  of  the  upper  end  of  the  bone,  very 
extensive  resection. 

This  method  will  avoid  septic  complications  and  dis-. 
articulation.     But  there  are  certain  complicated  cases, 
such  as  multiple  fractures  of  the  shoulder  girdle  or 
co-existing  wound  of  the  chest,  which  demand  special 
treatrnxcnt. 

{a)  If  a  fracture  of  the  humerus  is  complicated  hy 
multiple  fractures  in  its  vicinity,  such  as  fracture  of 
the  coraco-acromial  arch,  of  the  glenoid  cavity,  and 


112     THE   TREATMENT   OF  FRACTURE,^ 

especially  of  the  scapula  (a  frequent  occurrence),  very 
careful  clearing  out  with  sub-periosteal  removal  of 
the  fragments  is  more  necessary  than  ever.  In  cases 
of  this  kind  I  have  seen  disarticulation  performed  at 
the  shoulder-joint  followed  by  partial  resection,  of  the 
scapula.  It  is  an  over- rated  method :  esquillectomy 
is  quite  sufficient  if  it  is  properly  performed. 

{h)  If  there  are  concoynitayit  jnihnonary  injuries, 
which  is  frequent,  the  case  is  difficult  :  on  the  one  hand 
the  condition  of  the  lungs,  the  dyspnoea,  and  the  shock 
contra -indicate  even  a  short  anaesthesia  ^  while  on  the 
other  hand  there  is  the  imminent  risk  of  formidable 
complications. 

It  is,  however,  possible  to  surmount  the  difficulty  : 
the  dyspnoeic  patient  should  have  some  morphine  at 
once  and  be  put  to  bed  wearing  a  sling  which  fixes  the 
fractured  limb  against  the  thorax.  After  the  lapse  of 
some  hours,  when  the  dyspnoea  is  less  and  the  patient 
is  better,  the  sHng  is  removed,  and  after  another  injec- 
tion of  morphine  the  scapular  wound  is  laid  open 
freely  with  scissors,  and  when  thus  exposed  to  the 
air  it  is  no  longer  exposed  to  primary  gas  gangrene 
or  fulminating  sepsis.  Without  interfering  with  the 
deeper  structures,  the  arm  is  again  fastened  to  the 
thorax.  In  this  way  one  can  safely  wait  without 
causing  aggravation  of  the  pulmonary  condition. 
As  soon  after  this  as  the  state  of  the  chest  will  permit, 
further  surgical  intervention  will  be  necessary.  These 
patients  bear  an  anaesthetic  fairly  well,  especially  if 
it  is  preceded  by  an  injection  of  morphine. 

III.   Operative  Technique 

1.  Means  of  Access  to  the  Articulation. — Every 
operation  on  the  shoulder  must  be  dominated  by  the 
desire  to  preserve  the  attachments  and  the  nerve- 
supply  of  the  deltoid.  Its  nerve,  the  circumflex, 
emerges  from  the  axilla  between  the  humerus  and  the 


THE  i^HOVLDER 


113 


outer  edge  of  the  long  head  of  the  triceps,  runs  round 
the  surgical  neck  which  it  embraces  hke  a  collar  in 
company  with  the  posterior  circumflex  artery,  and 
approaches  the  joint  as  it  runs  towards  the  front  of 
the  shoulder.  On  its  way  it  gives  off  branches  which 
pass  vertically  into  the  deltoid  muscle,  and  terminate 
at  its  anterior  border.  The  nerve  thus  runs  more  or 
less  parallel  with  the  outer 
border  of  the  acromion, 
from  which  it  is  distant, 
in  an  adult  of  medium 
height,  about  2|-  inches 
No  posterior  incisions, 
therefore,  should  be  made 
at  this  level  lest  they 
should  divide  the  nerve 
and  thus  paralyse  the 
greater  part  of  the  muscle. 
The  area  of  election  for  an 
incision  is  the  front  of  the 
shoulder,  just  outside  the 
interval  between  the  del- 
toid and  the  pectoralis 
major,  which  interval  is 
itself  to  be  avoided  be- 
cause of  the  cephalic  vein. 

In  a  general  way  any 
wound  of  entry  or  exit  of 
a  missile  lying  outside  the  area  mentioned  above  should 
be  looked  upon  as  not  available  as  a  route  to  get  access 
to  the  head  of  the  bone,  but  rather  as  an  opening  that 
can  be  made  use  of  for  drainage. 

These  general  principles  being  laid  down,  the  pro- 
cedure should  be  as  follows: 

(a)  When  there  is  no  posterior  wound,  an  exploratory 
incision  is  made  at  the  level  of  the  wound  of  entry ;  it 
should  not  extend  below  the  limits  indicated  above.  If 
there  is  not  enough  room,  it  should  be  extended  upwards 


Fig.  13. — Distribution  of  the 
circumflex  nerve  over  the  back 
of  the  shoulder,  showing  why 
posterior  incisions  should  be 
avoided  if  possible,  to  obviate 
paralysing  the  deltoid. 


114     THE   TREATMENT  OF  FRACTURES 


to  the  posterior  border  of  the  acromion,  from  which 
the  insertion  of  the  deltoid  should  be  separated  with 
a  rugine  for  about  half  an  inch  or  so. 

If,  after  incising  the  deep  fascia  and  exposing  the 
joint,  a  limited  injury  is  found  that  can  be  dealt 
with   by  a    superficial   esquillectomy   and    extraction 

of  the  missile,  this  explora- 
tory incision  will  suffice.  If, 
on  the  contrary,  the  bony 
lesions  are  extensive,  and  if 
there  is  a  comminuted  frac- 
ture of  the  head  necessitating 
resection,  the  classical  anterior 
incision  must  be  made,  the 
posterior  opening  serving 
simply  as  a  means  of  securing 
the  necessarj^  drainage. 

(6)  When  there  is  an  irregu- 
lar wound  with  smashing  up 
of  the  head,  and  in  all  cases 
in  which  resection  appears 
necessary,  an  anterior  incision 
should  be  made  at  once  with- 
out troubling  about  the  wound 
of  entry. 

This  incision,  beginning  half 
an  inch  below  the  clavicle, 
runs  downwards  and  outwards  in  the  direction  of  the 
fibres  of  the  deltoid  as  far  as  may  be  necessary.  If 
there  is  not  enough  room  above,  the  insertion  of  the 
deltoid  into  the  clavicle  can  be  removed  for  about  an 
inch.  The  edges  of  the  incision  in  the  muscle  are 
drawn  apart  and  the  articulation  is  exposed.  Even 
when  the  capsule  is  torn,  although  there  may  be  severe 
damage  to  it,  it  is  important  to  make  the  incision  to 
the  outer  side  of  the  tendon  of  the  biceps  and  parallel 
to  it.  This  structure  can  be  defined  accurately  by 
rotating  the  humerus  a  few  times. 


Fig,  14. — The  best  inci- 
sion for  exposure  of  the 
shoulder- joint. 


THE  SHOULDER  115 

'1.    SUBCAPSULO-PERIOSTEAL    DENUDATION  :    SECTION 

OF  THE  Bone. — From  this  point  onwards  the  cutting 
rugine  alone  ought  to  be  used.  If  the  fragments  of  the 
head  are  too  freely  movable,  they  should  be  fixed 
with  forceps,  so  that  the  periosteum  can  be  stripped  off, 
biting  into  the  bony  tissue  rather  than  leaving  any  of 
the  fibrous  attachments  adherent  to  it.  In  this  way 
the  insertions  of  the  supra-spinous  and  teres  minor 
muscles  on  the  outside  will  be  carefully  detached,  the 
humerus  meanwhile  being  internally  rotated ;  on  the 
inside  the  insertion  of  the  subscapularis  is  similarly 
treated,  the  humerus  being  rotated  externally.  It  is 
important  to  strip  off  the  periosteum  everywhere,  and 
to  tear  nothing,  so  as  to  preserve  as  far  as  possible 
the  capsular  periosteum  as  well  as  the  insertions  of 
the  muscles. 

//  the  missile  has  struck  the  up'per  part  of  the  head 
of  the  humerus,  splintering  the  intra-articular  portion, 
it  is  enough  to  clear  the  joint  cavity  of  all  bony  frag- 
ments and  smooth  off  any  projecting  points  with  a 
chisel,  so  as  to  shape  the  extremity  of  the  humerus 
to  the  glenoid  cavity. 

//  the  head  of  the  humerus  has  been  split  vertically, 
the  part  that  remains  attached  to  the  shaft  is  pre- 
served, and  its  surface  is  trimmed  with  bone  forceps, 
which  should  be  made  to  remove  the  articular  cartilage 
as  well. 

If  the  end  of  the  bone  has  been  extensively  commi- 
nuted, the  whole  of  the  head  is  removed,  leaving  only 
any  large  fragment  of  the  tuberosity  that  may  be 
present.  If  necessary,  the  saw  is  applied  through  the 
surgical  neck.  No  notice  need  be  taken  of  fissures 
running  down  into  the  shaft.  They  repair  of  them- 
selves when  the  principal  injury  has  been  suitably 
treated. 

//  the  upper  extremity  of  the  Mimerus  has  jeen 
entirely  destroyed,  it  must  not  be  thought  that  the 
injury  to  the  bone  is  too  great  to  admit  of  cure,  and 


116    THE   TREATMENT  OF  EMACTUMES 


that  disarticulation  must  be  performed.  The  anterior 
incision  should  be  enlarged  as  much  as  may  be  needful 
and  the  fragments  of  the  head  and  shaft  carefully, 
removed  by  means  of  the  rugine  and  followed  down  as 
far  as  necessary.  Any  very  large  fragments,  em- 
bracing one-fourth  the  circumference  of  the  shaft, 
should  be  spared.     But  in  these  cases  there  must  not 

be  undue  economy  of  bone 
in  order  to  save  the  limb. 
By  removing  from  five  to 
six  inches  of  humerus,  I 
have  succeeded  in  avoid- 
ing disarticulation,  even 
where  there  were  other  ac- 
companying fractures,  of 
the  inferior  maxilla  in  one 
case,  of  the  radius,  the 
ulna,  and  of  the  skull  in 
another. 

//  the  fracture  of  the 
humerus  is  co7nplicated  by 
fracture  of  the  body  of  the 
scapula,  the  method  will  be 
the  same,  and  it  should 
not  be  thought  that  the 
injuries  are  too  extensive 
to  admit  of  conservative 
treatment.  The  coraco- 
acromial  fractures  should 
be  cleared  in  the  same  way 
as  the  humerus,  but  less 
freely.    When  the  articular 


Fig.  15. — Comminuted  frac- 
ture of  the  head  of  the  humerus 
caused  by  a  shell-spHnter  with 
extensive  destruction  of  mus- 
cular tissue.  Removal  by  the 
rugine  of  the  head  of  the  bone 
and  many  fragments  obviated 
disarticulation  and  has  pre- 
served a  useful  upper  limb. 
A  cure  was  obtained  in  two 
and  a  half  months  without  any 
sinus. 


cavity  is  cleared,  these 
injuries  run  a  favourable  course  ;  if  the  glenoid  cavity 
is  broken,  complete  scapulo-humeral  resection  should 
be  done  by  means  of  a  deltoid  flap,  turning  the  muscle 
off  its  attachment  to  the  acromion. 

When  there  is  a  fracture  of  the  body  of  the  shoulder- 


THE  SHOULDER  nil 

blade,  the  scapular  wound  should  be  incised  and  the 
fracture  treated  by  an  extensive  esquillectomy.  Unless 
this  is  done,  severe  septic  infection  may  take  place  in 
the  subscapular  fossa  and  endanger  life. 

Likewise  if  the  glenoid  cavity  is  broken,  free  esquillec- 
tomy should  be  performed:  sufficient  articular  sup- 
port will  be  obtained  if  the  periosteum  is  preserved. 

Whatever  may  be  the  extent  of  the  intervention, 
every  resection  of  the  shoulder  and  every  intra-articu- 
lar  esquillectomy  of  any  importeince  should  be  com- 
pleted by  a  posterior  counter-opening  for  drainage  at 
the  seat  of  election,  that  is  above  the  circumflex, 
utiUsing  if  possible  one  of  the  wounds  made  by  the 
missile. 

IV.  Post-Operative  Treatment 

1.  Temporary  Dressing  and  Immobilisation. — 
When  posterior  drainage  has  been  established,  the 
anterior  resection  or  esquillectomy  wound  is  plugged 
with  aseptic  gauze.  While  an  assistant  supports  the 
elbow,  and  holds  it  slightly  away  from  the  body,  an 
absorbent  dressing,  thicker  behind  than  in  front,  is 
applied.  Before  this  is  done,  care  is  taken  to  fix  the 
drainage  tube  with  a  pin,  and  to  cut  it  of!  very  short, 
so  that  the  pressure  of  the  dressing  cannot  make  the 
contact  unbearable. 

Immobilisation  can  be  done  in  two  ways. 

(a)  If  the  patient  remains  on  the  spot  and  can  be 
followed,  especially  when  the  operation  on  the  bone 
has  been  important,  and  when  an  abundant  discharge 
from  the  wound  is  expected,  it  is  only  necessary  to 
keep  the  arm  against  the  side  by  means  of  the  dressing, 
the  elbow  being  bent  and  the  hand  brought  up  across 
the  chest.  After  the  limb  has  been  surrounded  with 
wool,  it  is  fastened  to  the  chest  by  a  circular  bandage 
which  supports  the  elbow  by  means  of  turns  of  band- 
age passing  over  the  sound  shoulder.     This  bandage, 


118    THE   TREATMENT  OF  FRACTURES 

which  is  similar  to  that  for  dislocation  of  the  shoulder, 
secures  perfect  immobility  when  it  is  well  applied,  and 
the  patients  on  whom  it  is  used  do  not  complain.  I 
use  it  habitually  in  the  early  stages  of  treatment. 

[h]  When  it  is  seen  that  the  dressing  will  be  able 
to  remain  in  position  for  several  days,  and  the  wound 


"^,1  ,,  ■  ■ 

% 

t:.^ 

r"" 

1 

Fig.    16. — Pattern  of  casing  for  immobilising  the  upj)er  limb 
and  23articularly  the  shoulder. 

will  progress  aseptically,  or  stili  more,  if  the  patient 
is  liable  to  unexpected  evacuation,  a  plaster  casing 
should  be  made  in  the  following  manner :  The  splint 
is  made  of  a  dozen  thicknesses  of  tarlatan  the  length 
of  the  limb — measured  from  the  prominence  of  the 
shoulder  to  the  thumb  with  the  elbow  flexed — ^increased 
by  about   16  inches).      This  is  cut  so  as  to  obtain  : 

(1)  A  covering  for  the  postero-external  surfaces  of 
the  arm  and  forearm  and  the  ulnar  side  of  the  hand, 
embracing  more  than  half  of  the  circumference  of 
the  arm  above,  and  just  half  the  circumference  of  the 
forearm  below. 

(2)  Two  bands  to  pass  obliquely  across  the  thorax. 

The  upper  part  of  the  splint  will  form  a  shoulder- 
cap,  closely  embracing  the  prominence  of  the  shoulder. 
To  make  sure  of  a  perfect  fit,  the  two  thoracic  bands 
are  crossed  over  each  other  before  carrying  them  across 
to  the  opposite  axilla,  so  that  their  overlapping  may 
strengthen  the  zone  of  flexion.  At  the  level  of  the 
elbow  two  notches  are  cut  to  permit  of  flexion  (fig.  16). 
For  the  evacuation  of  elbow  wounds  a  plaster  casing 
identical  with  that  shown  in  fig.  41  may  be  made. 

This  casing  is  fixed  by  means  of  bandages  which  go 


THE  SHOULDER 


119 


round  the  thorax  above.  If  care  is  taken  to  put 
wool  in  the  axilla  to  keep  the  humerus  in  good  position, 
i.e.  to  prevent  the  tendency  to  adduction  produced 
by  the  pectoralis  major,  this  casing  will  last  for  many 
dressings  :  it  is  removed  .^T-nj)z 

at  each  dressing,  and  re-  ^^-^  --.^ 

applied  if  the  discharges 
have  not  robbed  it  of  its 
firmness.  . 

2.  Later  Dressings 
AND  Permanent  Immo- 
bilisation. —  There  is 
every  reason  to  delay  the 
dressing  as  late  as  pos- 
sible :  it  is  well  not  to 
change  it  for  three  or  four 
days,  even  if  it  is  very 
soiled,  or  longer  if  pos- 
sible. Sometimes  severe 
pain  makes  it  necessary 
to  inspect  the  wound  ear- 
lier.    This  pain   is    often 

due  to  the  posterior  drainage  tube,  which,  being  of 
use  only  during  the  first  forty-eight  hours,  can  be 
withdrawn  for  good  or  replaced  by  a  smaller  one. 
As  soon  as  the  wound  is  healing  well,  the  dressings  can 
be  facilitated  by  using  a  plaster  apparatus  provided 
with  a  window  or  a  metal  interruption.  The  extent 
of  the  wound  ought  to  decide  the  choice  between  these 
patterns,  which  are  made  in  the  following  manner  : 

{a)  If  the  wound  is  not  too  extensive  and  there  is 
little  discharge,  and  if  its  edges  are  supple,  a  "  win- 
dowed "  splint  will  be  made. 

To  do  this,  the  thorax  is  covered  with  a  jersey,  or 
a  roll  of  gauze,  and  a  jacket  is  made  by  means  of 
plaster  bandages.  It  is  not  necessary  to  incorporate 
any  splinting.  Two  or  three  bandages  5j  yards  long 
will  suffice  to  cover  the  thorax  with   a   firm   plaster 


Fig.   17. — The  casing  applied. 


120    THE  TREATMENT  OF  FRACTURES 


shield,  moulded  over  the  shoulder  and  both  clavicles. 
When  the  thickness  is  considered  sufficient,  the 
bandage  is  carried  in  figures -of -eight  from  the  shoulder 
over  the  upper  limb  round  the  axilla,  and  then  down 

over  the  arm 
and  forearm  as 
far  as  the  meta- 
carpus. T  h  e 
arm  is  fixed  in  a 
position  of  ab- 
duction, the  el- 
bow slightly 
away  from  the 
body,  and  the 
forearm  flexed 
midway  be- 
tween  pronation 
and  supination, 
the  thumb  up- 
ward. The  up- 
per limb  being 
c  ompletely 
covered  in  regu- 
lar turns  with 
three  bandages, 
windows  to  dis- 
play the  wounds 
are  cut  out  witli 
a  knife,  whilst 
the  plaster  is 
drying.  The 
openings  should  be  large  enough  to  prevent  the  plaster 
from  being  soiled,  and  some  dressing  should  be  slipped 
under  their  edges  to  avoid  friction  ;  the  casing  is  also- 
cut  away  beneath  the  axilla.  This  sphnt  should  be 
worn  for  a  month,  at  the  end  of  which  time  cicatri- 
sation will  generally  be  complete.  A  sUng  may  then 
be  substituted  and  movements  commenced. 


Fig.   18. — Casing  with  window. 


THE  SHOULDER 


121 


(6)  If  the  wound  is  very  extensive  and  large  openings 
are  called  for,  a  bracketed  apparatus  should  be 
employed.  This  will  be  constructed  in  accordance 
with  the  general  rules  of  immobilisation,  that  is  to 
say,  it  will  take  in  the  trunk  and  the  elbow.  In  order 
that  the  arm  may  be  well  supported,  a  metal  triangle 
made  out  of  a  piece  of  bent  hoop-iron,  or  some  similar 


i  / 


i^K- 

^Hj 

■-~:;-.^ 

^^I^^^^^^ 

-^-r 

"^^^s^ 

_ 

/ 

_3 

•7^ 

L_ 

— — — H 

..-^^ 

^^ 

'""x 

Fig.  19. — Casing  with  triangle  : 
details  of  application.  Diagran^ 
shows  triangte  in  axilla  and  its  in- 
corporation into  the  plaster  jacket 
and  the  bandages  which  encircle  the 
npper  limb.  The  numbers  indicate 
the  order  in  which  the  iMter  are 
applied.  The  hand'  should  be  held 
so  as  to  support  the  wrist. 


rigid  suppoi-t,  is  placed  in  the  axilla.  Each  side  of 
this  equilateral  triangle  will  be  from  6  to  8  inches 
in  length. 

The  apparatus  will  comprise  : 

(a)  A  plaster  jacket  covering  the  wounded  shoulder, 
made  with  three  or  four  bandages  5J  yards  long. 


122     THE   TREATMENT  OF  FRACTURES 

(b)  A  bandage  going  round  the  upper  limb  from 
the  shoulder  to  the  lower  border  of  the  metacarpus 
(three  bandages). 

(c)  A  triangle  made  of  hoop  iron,  padded  with  wool 
surrounded  by  a  gauze  bandage. 

(d)  An  interruption  of  iron  wire  shaped  hke  a  bridge  ; 
the  arms  of  this  bracket,  whose  extremities  will  be 
raised  a  little  to  prevent  it  from  slipping,  take  purchase 


Fig.  20. — The  same  casing  completed  ;    a  bandage  supports 
the  forearm  and  hand. 

above  from  the  cervical  side  of  the  coraco-acromial 
arch,  in  a  line  from  the  shoulder  to  the  nape  of  the 
neck ;  and  below,  from  the  lower  part  of  the  arm 
below  the  wounds. 

The  plaster  will  commence  with  the  corset,  in  which 
will  be  incorporated  the  thoracic  side  of  the  axillary 
triangle.  When  that  has  been  well  fixed,  the  bandage 
will  pass  over  the  shoulder  in  a  figure-of-eight  round 


THE  SHOULDER 


123 


the  axilla  and  the  neck  ;  then  it  is  carried  down  the 
arm,  fixing  the  humeral  side  of  the  metal  triangle. 
Then  follows  envelopment  of  the  elbow  and  the  hand 
in  the  position  already  indicated. 

Lastly,  the  metal  interrupting  bracket  will  be  placed 
in  position  and  fixed  to  the  plaster  casing  by  another 
bandage.  All  that  remains  to  be  done  is  to  cut  the 
plaster  bandage  away  from  the  area  of  the  wounds 
and  smooth  off  the  edges  of  the  apparatus. 

3.  Mobilisation, — This  ought  not  to  be  commenced 


Fig.  21. — Result  of  primary  resection  for  comminuted  fracture 
of  the  head  of  the  humervis,  after  six  months.  The  scar  of  the 
anterior  incision  is  distinctly  seen  on  the  right  shoulder.  The 
arm  of  the  side  operat'ed  on  appears  to  be  raised  higher  than  the 
other,  but  by  examining  the  line  of  the  shoulder  it  is  easy  to  reaHse 
that  the  shoulder-blade  takes  jDart  in  the  movement, 

too  early.  It  is  necessary  indeed  to  wait  until  the 
humerus  is  sufficiently  fixed  against  the  glenoid  cavity, 
before  seeking  to  get  even  slight  movement.  Unless 
this  precaution  is  observed,  the  humeral  extremity 
may  be  dislocated  by  the  adductor  muscles  below 
and  in  front  of  the  coracoid  process,  and  the  result 
will  be  deplorable. 
If  resection  has  been  limited  to  the  head,  no  move- 


124     THE   TREATMENT  OF  FRACTURES 

ments  should  be  commenced  for  a  month.  In  case 
of  more  considerable  loss  of  bone,  a  longer  period  is 
required  ;  but  as  soon  as  cicatrisation  is  advanced  a 
little  the  muscles  should  be  either  massaged  or  electri- 
fied. Exposure  to  the  sun  is  one  of  the  best  agents 
for  the  preservation  of  muscles.  Before  any  attempt 
is  made  at  passive  movement,  voluntary  contraction 
of  the  muscles  should  be  promoted  with  the  limb  still 
fixed.  Elevation  and  rotation  should  be  the  first 
movements  attended  to.  Abduction,  which  is  the 
most  useful  movement,  is  the  most  difficult  to  obtain. 
That  is  due  principally  to  injury  to  the  deltoid.  Out 
of  ten  patients,  I  have  only  obtained  it  satisfactorily 
in  two. 

As  a  general  rule,  and  contrary  to  what  happens 
in  the  elbow,  undue  laxity  of  the  joint  is  to  be  feared, 
rather  than  ankylosis. 

V.   Evacuation  of  Patients  with  Shouldei  Wounds 

With  the  exception- of  mere  tracks  with  punctiform 
openings,  all  wounds  of  the  shoulder  ought  to  be 
explored  as  soon  as  possible.  None  ought  to  be  con- 
sidered as  primarily  mild. 

Removal  to  the  base,  without  a  clearing  operation, 
ought  not  to  be  practised  unless  there  is  consider- 
able over-crowding,  when  it  becomes  clear  that  the 
patient  will  be  more  quickly  operated  upon  if  he  is 
moved  than  if  he  remains  in  situ.  In  this  case  the 
patient  ought  always  to  be  detained  in  the  first 
surgical  line  (relai)  he  comes  to.  He  should  never 
travel  for  more  than  twenty-four  hours. 

What  is  the  most  favourable  time  for  evacuation  of  a 
patient  ivho  has  undergone  esquillectomy  or  resection  ? 
It  is  at  the  end  of  a  week,  if  the  patient  cannot  be 
kept  longer.  Simple  esquillectomies  can  travel  after 
three  or  four  days,  with  their  injured  limb  immobihsed 
in  a  plaster  casing  designed  for  that  purpose.     After 


THE   SHOULDER  ViTy 

extensive  operations  for  the  removal  of  bone,  as  for 
destruction  of  the  upper  half  of  the  humerus,  it  is 
advantageous  to  retain  the  patient  as  long  as  possible, 
fifteen  days  at  least. 

Apparatus  for  transport. — ^The  plaster  splint  de- 
scribed above  (see  fig.  18)  is  generally  sufficient.  A 
plaster  casing  of  the  Hennequin  type  may  also  be 
used.  The  elbow  should  be  slightly  adducted  with- 
out being  in  contact  with  the  wall  of  the  thorax,  the 
forearm  flexed,  and  the  axillary  pad  in  place.  This 
apparatus  should  be  removed  on  his  atrival.  The 
journey  should  not  exceed  forty-eight  hours. 

VI.  Treatment  of  Patients  seen  late  or  after  Evacuation 
1.  A  Patient,  who  has  been  lying  out  for  some 

TIME,   AKRIVES    AT    THE   AMBULANCE    AT    THE    END     OF 

24  TO  36  Hours. — ^There  are  all  the  signs  of  a  com- 
mencing suppurative  arthritis,  or  of  a  diffuse  phleg- 
monous inflammation  of  the  shoulder,  often  gaseous. 
The  wound  is  sloughing  and  looks  foul. 

The  sloughing  edges  should  be  immediately  excised. 
Sub-periosteal  removal  of  all  the  fragments  that  are 
free  and  those  that  are  adherent  and  likely  to  interfere 
with  drainage  should  be  done  at  once  through  an 
anterior  incision.  It  is  really  an  extensive  resection, 
atypical,  like  the  bone  section,  having  for  its  object 
the  free  exposure  of  the  seat  of  the  articular  fracture. 
If  the  fracture  is  incomplete,  immediate  resection  of 
the  head  of  the  humerus  should  be  done. 

If  the  humerus  is  smashed  up  and  septic,  sub- 
periosteal removal  of  the  bone,  described  above,  will  be 
the  operation  of  choice  and  will  generally  check  the 
infection  ;  if  it  persists,  however,  especially  in  a  case 
of  comminuted  fracture,  or  if  at  the  outset  the  gravity 
of  the  general  condition  makes  one  doubtful,  disarticu- 
lation at  the  shoulder-joint  should  be  done  without 
hesitation. 


126     THE   TREATMENT  OF  FRACTURES 

2.  A  Patient  correctly  operated  upon  at  the 
Front  arrives  at  the  Base  in  good  condition. — 
(a)  A  patient  who  has  had  early  arthrotomy  with 
removal  of  all  foreign  bodies  for  parietal  fracture, 
gets  well  rapidly.  In  three  weeks  fixation  should  be 
abandoned,  and  gentle  movement  commenced.  Treat- 
ment by  mechanical  movement  is  expressly  contra- 
indicated.  As  soon  as  active  movements  can  be  per- 
formed, the  patient  himself  will  do  all  his  own  movement. 

(6)  In  the  case  of  a  patient  who  has  undergone 
arthrotomy  for  a  splintered  fracture,  and  is  doing  well, 
it  is  necessary  to  promote  ankylosis  by  strict  immo- 
bility. The  limb  is  very  slightly  abducted,  the  elbow 
just  away  from  the  body,  and  no  heed  should  be  taken 
of  loss  of  movement,  which  is  inevitable. 

(c)  A  patient  who  has  had  resection  performed  ought 
to  be  treated  according  to  the  indications  given  above. 

3.  A  Wounded  man  arrives  without  having  been 

OPERATED     UPON,    AND    WITHOUT    ANY    SYMPTOMS     OP 

serious  INFECTION. — Suppose  a  patient  arrives  on 
the  third  day  ;  one  confines  one's  energies  to  enforcing 
strict  immobility  by  means  of  a  plaster  splint,  made  as 
described  above.  Some  days  later,  aided  by  radio- 
graphs, a  search  can  be  made  for  missiles,  if  there  be 
any,  or  dead  fragments  of  bone.  These  cases  get  well, 
but  often  with  ankylosis  and  sinuses. 

4.  The  Operative  Treatment  has  been  carried 
out  late,  or  early  treatment  has  been  insuffi- 
CIENT.— The  patient  arrives  in  a  septic  condition  with 
free  suppuration. 

[a]  An  arthrotomy  and  esquillectomy  have  been 
performed,  but  the  radiograph  shows  missiles  left  be- 
hind or  fragments  of  bone  in  a  fair  way  to  necrosis. 
After  forty-eight  hours  of  observation  and  rest,  what- 
ever the  date  of  the  injury,  it  will  be  necessary  to 
complete  the  first  operation  and  to  remove  missiles 
and  fragments,  carefully  sparing  all  periosteal  remains, 
and  excising  dead  tissues,  generally  fragments  of  an 


THE   SHOULDER  127 

aponeurosis  or  tendons.  Even  should  the  short  head 
of  the  biceps  be  concerned,  it  should  be  cut  away,  for 
a  tendon  does  not  recover,  and  takes  a  long  time  to 
come  away  spontaneously.  If  the  bony  lesions  are 
extensive,  resection  of  the  head  of  the  humerus,  which 
is  the  operation  of  choice,  will  be  done  without  hesita- 
tion. 

(6)  The  injury  to  the  bone  has  not  been  touched. 
There  is  suppurative  arthritis  starting  from  a  septic 
centre  in  the  bone  ;  the  best  treatment  is  resection  of 
the  humeral  head.  Arthrotomies  do  not  drain  so  well, 
nor  do  they  allow  the  cause  to  be  reached.  On  the 
other  hand,  late  resections,  if  they  are  not  too  late, 
often  give  very  good  results  ;  the  recovery  of  function 
is  often  better  than  with  primary  resections  :  if  one 
were  sure  of  being  always  just  in  time,  the  general 
indication  would  be  to  wait.  At  least  that  is  the 
accepted  opinion i  But  it  rests  on  no  precise  reason  : 
periosteal  regrowth  occurs  quite  as  well  in  a  primary 
as  in  a  secondary  resection.  In  short,  the  function  of 
the  new  joint  depends  above  all  On  two  factors  :  the 
conditions  of  the  muscles,  and  the  extent  of  the  bony 
loss.  Whatever  may  come  of  the  argument,  one  will 
resect  with  hope  of  a  good  functional  result. 

If  there  are  purulent  sinuses  round  the  joint,  notably 
behind  and  internally,  resection,  combined  with 
counter-openings  and  complete  cleaning  out  of  dead 
fragments,  will  almost  always  enable  one  to  avoid 
disarticulation.  That  will,  however,  sometimes  be 
necessary  in  consequence  of  the  gravity  of  the  general 
condition,  especially  if  scapular  injuries  co-exist. 

5.  The  Patient  arrives  with  his  wounds  almost 
HEALED. — (a)  A  sinus  persists.  Generally  this  is  at 
the  antero-intemal  part,  quite  near  the  axilla — at 
least  I  have  always  seen  it  there.  After  radiography 
the  dead  bony  fragment,  or  the  missile  which  keeps 
up  the  sinus,  is  sought  for,  even  by  doing  a  sub-car- 
tilaginous scraping  out  of  the  spongy  tissue  of  the 


128     THE   TREATMENT  OF  FRACTURES 

head  of  the  bone.  This  curettage  generally  ensures  a 
complete  recovery,  but  the  wound  must  be  kept 
freely  open,  and  no  attempt  must  be  made  to  obliterate 
the  cavity  by  an  antiseptic  paste,  which  would  cer- 
tainly be  extruded.  Sunlight  benefits  these  old  bone 
cases  marvellously. 

(6)  The  limb  is  flail-like  from  want  of  bony  growth. 
One  must  distinguish  between  two  types  of  this 
condition  :  limbs  which  are  active  though  flail-like, 
and  those  which  are  absolutely  useless.  In  those  which 
retain  some  activity,  the  muscles  are  still  in  a  good 
condition,  a  correctly  performed  operation  has  made 
the  best  of  them,  has  saved  their  nerve  supply  and 
maintained  their  attachment  to  the  periosteal  sheath. 
They  preserve  their  power  of  contraction,  are  able  to 
raise  the  lower  end  of  the  humerus  with  some  strength, 
and  thus  permit  useful  movements.  In  these  cases 
one  is  tempted  to  think  of  bone-grafting.  At  the 
present  time  the  operation  seems  inadvisable  and  not 
likely  to  succeed  ;  the  graft  would  be  liable  to  be  dis- 
placed, if  not  absorbed.  In  a  case  of  this  kind  in  a 
patient,  two-thirds  of  whose  humerus  I  had  resected 
as  well  as  the  ends  of  the  two  bones  of  the  forearm  at 
the  elbow,  a  supporting  case  fitting  on  to  the  shoulder 
has  permitted  him  to  use  the  limb. 

In  those  arms  which  are  flail-like  and  quite  useless, 
where  there  are  no  longer  any  muscles,  suspension  must 
be  resorted  to  by  means  of  an  apparatus  encircling  the 
trunk  and  shoulder,  with  a  firm  casing  enclosing  the 
arm,  and  giving  a  solid  point  of  support  for  the  move- 
ments of  the  elbow  and  the  hand.     (See  fig.  97.) 


CHAPTER    III 
WOUNDS   AND  FRACTURES   OF  THE  ELBOW 

I.    Anatomical  Types  and  Clinical  Course 

Every  wound  in  the  region  of  the  elbow;  even  if  it 
extends  to  the  bone,  is  not  necessarily  a  wound  of  the 
joint.  Projectiles  often  chip  the  surface  of  one  of 
the  bones,  without,  strictly  speaking,  penetrating  the 
joint.  These  wounds,  which  may  be  called  parietal 
or  para -articular,  generally  run  a  very  simple  course 
after  a  suitable  incision  has  been  made  for  the  removal 
of  the  foreign  body  and  any  dead  organic  debris. 
Scarcely  any  limitation  of  the  movements  of  the  elbow^ 
is  left  when  they  heal.  I  have  seen  a  dozen  cases 
like  this,  but  it  is  not  necessary  to  take  them  into 
account  in  speaking  of  wounds  of  the  joint,  and  they 
will  not  be  considered  further  here. 

One  only  really  considers  as  fractures  of  the  elbow 
injuries  to  one  at  least  of  the  three  bone  ends  inside 
the  synovial  membrane. 

Theoretically  the  elbow  can  be  traversed  through 
and  through  without  the  bone  being  damaged,  but  in 
practice  this  very  rarely  happens.  As  a  general  rule, 
ever^^  clean  perforating  bullet  wound  of  the  elbow, 
however  simple  it  may  appear  and  whatever  be  its 
direction,  is  accompanied  by  injury  to  both  bone  and 
cartilage,  even  when  radiography  shows  nothing  ; 
when  it  does  show  anything,  there  is  always  more 
damage  than  is  apparent. 

One  bone  only  may  be  struck,  but  that  is  excep- 

129 


130     THE  TREATMENT  OF  FRACTURES 


tional ;  out  of  thirty-six  cases,  verified  by  operation,  I 
have  only  observed  this  three  times.  More  often,  the 
fracture  impHcates  two  bones  ;  when  the  principal 
injuries  are  those  of  the  radius  or  the  ulna,  there  will 

be  extensive  damage  to 
the  corresponding  or  op- 
posite part  of  the  hu- 
merus, and  vice  versa. 
Similarly,  the  two  upper 
articular  ends  of  the 
bones  of  the  forearm 
may  be  broken  simulta- 
neously. Besides,  it  is 
easy  to  understand  that 
all  possible  combinations 
may  occur,  according  to 
the  varying  path  of  the 
missile  and  the  different 
positions  of  the  arm  and 
forearm.  It  only  matters 
to  remember  that  there  is 
always  more  damage  than 
appears  from  the  symp- 
toms, and  that  the  frac- 
tures of  the  epiphyses 
are  often  prolonged  by 
fissures  far  down  the 
shaft. 

In  these  fractures, 
which     sometimes     are 
very  Httle   comminuted, 
as  is  especially  the  case 
in  the  humerus,  the  dis- 
placement is  usually  not 
considerable.        I     have 
always    seen    the    olecranon   but    slightly    displaced, 
and  simply  bent  forwards  and  drawn  up  to  the  level 
of  the  cavity  which  normally  receives  it.     The  head 


Fig.  22. — Fi-acture  of  the  elbow 
by  bullet  with  punctiforra  skin 
wounds.  Aseptic  course  in  spite 
of  extensive  bony  injuries.  Re- 
covery by  simple  immobilisation 
for  one  and  a  half  months,  with 
limitation  of  movement ;  flexion 
up  to  90  degrees,  extension  nor- 
mal. Patient  seen  in  consultation 
to  consider  the  advisability  of 
further  resection,  which  has  been 
rejected  as  useless. 


THE  ELBOW  131 

of  the  radius  remains  adherent  to  the  tendon  of  the 
biceps  by  its  periosteum.  The  corqnoid  process  is 
generally  drawn  forwards.  But  all  these  structures 
are  often  unrecognisable,  being  reduced  to  small 
spUnters  which  remain  either  in  the  region  to  which 
they  belong,  or  are  scattered  somewhere  about  the 
tom-up  articular  cavity.  The  missile,  too,  is  close  by, 
but  in  its  course  it  has  often  caused  fragments  of 
clothing  to  adhere  to  the  bony  points,  whence  the 
frequency  of  infection. 

Perhaps  the  most  frequent  type  is  complete  destruc- 
tion of  the  elbow  in  which  two  and  sometimes  all  three 
articular  ends  are  demolished  ;  there  only  remains  a 
sort  of  bony  mess  in  place  of  the  joint,  with  spUnters 
and  osteo-cartilaginous  fragments  more  or  less  widely 
scattered  about. 

What  becomes  of  these  different  injuries  if  they  are 
left  untreated  during  the  first  few  days  ? 

The  surgeon  at  the  front  has  to  distinguish  three 
categories  : 

Bullet  wounds  with  punctiform  openings. 

Wounds,  blind  or  otherwise  small  or  of  moderate 
size,  made  by  splinters  of  shell  or  grenade. 

Large  wounds  made  by  short-range  bullets,  or  by 
large  pieces  of  shell,  with  great  loss  of  the  soft  parts 
and  smashing  up  of  the  elbow. 

(a)  The  fractures  caused  by  bullets  with  small 
punctiform  skm  openings  are  the  mildest  ;  they 
usually  heal  without  sepsis,  if  the  limb  is  suitably 
immobilised.  It  must  be  remembered  that,  in  these 
cases,  it  is  not  the  extent  of  the  bony  injury  but  the 
dimensions  of  the  skin  wound  which  determines  the 
gravity  of  the  case.  With  a  small  fracture  and  a 
large  wound  of  exit,  sepsis  is  certain.  On  the  other 
hand,  an  aseptic  course  is  possible  when  there  is  great 
destruction  and  the  wound  is  very  small.  This  is  not 
because  the  infection  is  introduced  from  without 
inwards  by  the   cutaneous  wound,  but  because   the 


132     THE  TREATMENT  OF  FRACTURES 

bullet  which  gives  rise  to  small  skin-openings  is  really 
one  fired  from  ^  distance,  hitting  the  body  point  fore- 
most, and  not  generally  carrying  anything  with  it.  It 
is  the  famous  "  humane  bullet "  ;  whilst  the  bullet  which 
produces  explosive  effects  is  deformed,  has  ricochetted 
or  is  wobbHng,  and  carries  with  it  debris  of  clothing 
and  leaves  behind  it  all  kinds  of  infective  organisms. 
The  wound  it  produces  has  the  same  elements  of  gravity 
as  one  caused  by  a  shell-spHnter,  and  no  distinctions  as 
to  the  variety  of  the  projectile  need  be  made. 

{h)  In  the  fractures  with  skin  wounds  of  small  or 
moderate  dimensions  apparently  of  a  mild  type  and 
caused  by  spHnters  of  shell  or  grenade,  it  is  almost 
necessary  to  reverse  the  formula  :  a  small  bHnd  wound 
is  more  formidable  than  a  large  open  one.  These  are 
generally  cases  with  small  skin  wounds  but  much  deep- 
seated  damage  which  is  shut  off  from  the  air,  and  is 
therefore  under  favourable  conditions  for  the  rapid 
development  of  septic  gangrene.  When  a  wound  is 
wide  open,  these  very  acute  symptoms  are  less  often 
observed  ;  ordinarily  an  acute  arthritis  occurs  with 
profuse  suppuration  and  discharge  of  sloughs  and 
necrosed  bone  ;  the  arm  becomes  enormously  swollen  ; 
purulent  sinuses  call  for  multiple  incisions  and  repeated 
removals  of  bony  fragments.  After  many  alarms  and 
several  operations,  the  patient  recovers  with  ankylosis 
and  with  or  without,  more  often  with,  sinuses. 

Even  if  cicatrisation  is  complete,  it  does  not  do  to 
think  that  everything  is  well ;  in  about  half  the  cases 
there  are  sequestra  in  the  ankylosed  bones,  or  granu- 
lation tissue  containing  spicules  of  bone  which  has  all 
the  appearance  of  tuberculous  tissue.  It  is,  how- 
ever, really  only  septic,  and  bacteriological  examina- 
tion shows  staphylococci  in  large  numbers.  They  may 
disappear  gradually,  but  for  a  long  time  this  latent 
infection  will  be  dangerous  :  it  explains  the  unexpected 
recurrences  of  infection,  the  painful  attacks  of  lym- 
phangitis on  the  occasion  of  a  chill  or  of  a  blow  on  the 


THE  ELBOW  133 

elbow,  and   in  many  cases  a  decided  decline  in  the 
general  health,  inexphcable  on  any  other  grounds. 

Out  of  twelve  resections  of  the  elbow  which  I  h^-ve 
performed  for  ankylosis  after  war-wounds,  I  have 
found  conditions  of  this  kind  in  seven.  In  the  other 
five  cases  the  ankylosis  had  ensued  in  the  ordinary 
course,  and  there  had  been  no  septic  relapses.  But 
in  two  cases  it  had  only  been  obtained  after  many 
operations  that  had  left  the  skin  adherent  to  the 
muscles  which  were  atrophied,  fibrous  in  character, 
and  with  much  diminished  functional  power :  in 
consequence  of  pain,  abundant  suppuration,  and 
repeated  dressings,  the  position  of  the  limb  had  been 
badly  overlooked,  and  after  eleven  months  of  painful 
treatment,  a  vicious  ankylosis  necessitated  resection 
for  the  deformity,  which  the  muscular  insufiiciency 
would  have  almost  contra-indicated. 

(c)  In  extensive  crushing  of  the  elbow  by  shell- 
splinters  or  the  explosive  effects  of  bullets,  one  may 
see  the  very  rapid  development  of  a  septicaemia 
which  ends  rapidly  in  death,  or  may  meet  the  pro- 
gressive aggravation  of  local  septic  phenomena  which 
calls  for  amputation,  if  the  life  of  the  patient  is  to 
be  saved. 

The  preceding  statements  can  be  reduced  to  the 
following  formulae  : 

Bullet  wound  with  purictiform  openings  =  simple 
development,  whatever  the  type  of  fracture. 

Bullet  wound  with  explosive  effects  =  rapid  and 
fatal  sepsis. 

Small  wound  by  shell- splinter  with  fracture  of 
varying  extent  =  gas  gangrene  or  rapidly  progressing 
sepsis  in  two  out  of  every  three  cases. 

Large  wound  by  shell- splinter  =  serious  sepsis  and 
septicaemia  of  a  more  or  less  rapid  type. 

To  sum  up,  except  in  bullet  wounds  with  puncti- 
form  openings,  sepsis  is  certain;  often  it  is  grave. 
Therefore,  as  it  is  impossible  to  foresee  w^hat  the  septic 


134    THE  TREATMENT  OF  FHACTUBES 

developments  will  be,  it  is  better  in  all  cases  to  do  a 
primary  operation  for  prophylaxis  and  disinfection, 
as  early  as  the  circumstances  permit,  so  as  to  render 
the  condition  aseptic  at  once. 

n.   Primary  Therapeutic  Indications 

We  will  put  aside  the  bullet  wounds  with  puncti- 
form  openings,  which  simply  require  an  aseptic  dress- 
ing and  immobilisation  in  a  plaster  casing  for  at 
least  three  weeks,  and  only  consider,  as  before,  the 
cases  under  discussion,  viz.  all  the  other  wounds  of 
the  elbow. 

Granted  that  "  armed  abstention,"  either  by  plaster 
case  or  splint,  is  dangerous,  and  that  a  primary  prophy- 
lactic operation  is  necessary,  three  possible  operations 
ought  to  be  considered  :  arthrotomy  with  or  without 
esquillectomy,  resection,  and  amputation.  To  one 
of  these  recourse  must  be  had  ;  for  one  should  never 
be  content  to  push  a  drainage  tube  through  from  the 
wound  of  entrance  to  that  of  exit,  a  practice  both 
illusory  and  useless,  and  always  dangerous  owing  to 
the  false  security  to  which  it  gives  rise. 

1.  Arthrotomy. — Arthrotomy  for  simple  explora- 
tion, done  through  an  incision,  close  to  the  outer 
border  of  the  olecranon  on  a  level  with  the  posterior 
wound  if  there  is  one  and  completed  by  a  postero- 
lateral incision  on  the  inside,  is  a  clearing  operation 
sufficient  for  slight  cases,  such  as  parietal  fractures, 
superficial  abrasions  of  a  bone,  detachment  of  a  chip 
of  the  humerus  or  ulna,  or  cancellous  crushhig  due  to 
a  missile  driven  into  the  bone  :  all  of  which  are 
wounds,  rather  than  fractures  of  bone,  strictly  speaking. 
But  arthrotomy  ought  to  permit  the  removal  of  any- 
thing that  is  detached,  and  the  cutting  off  of  what  is 
irregular  or  has  been  bruised.  In  these  conditions, 
even  if  there  is  a  radiating  fissure,  arthrotomy  done 
for  purjjoses  of  disinfection  and  extraction  of  missiles, 


THE  ELBOW 


135 


when  performed  quite  early,  is  an  excellent  operation, 
which  gives  the  best  results;  the  wounded  recover 
almost  complete  movement,  according  to  my  experience 
of  the  three  cases  in  which  I  have  used  it. 

But  when  the  injuries  are  more  considerable,  when 
an  intra-articular  fracture  is  present,  and  when  the 
necessary  measures  of  disinfection  and  clearing  are 
required  over  a  wider  area,  arthrotomy  is  insufficient, 


1 

{ 

) 
i 

k.~. 

m 

W 

YiG.  23. — Cancellous  fracture 
of  the  lower  extremity  of  the 
humerus,  the  projectile  remiaih- 
ing.  Primary  operation:  re- 
moval of  the  shell-splinter, 
curetting  of  the  bone,  and  asep- 
tic dressings. 


Fig.  24. — Radiograph  of  the 
injury  fifteen  days  after  opera- 
tion. Aseptic  course.  Recovery 
with  retention  of  movement. 


for  it  does  not  go  to  the  root  of  the  trouble.  It  can. 
and  often  does,  leave  in  the  joint  the  remains  of  cloth 
ing,  splinters  of  bone  and  dead  tissues,  which  are 
direct  predisposing  causes  of  sepsis,  gas  gangrene, 
arthritis,  and  above  all  acute  osteomyelitis,  often 
necessitating  amputation,  and  leading  to  a  fatal  issue. 
As  a  rule  it  is  advisable  to  complete  an  arthrotomy 
by  doing  esquillectomy. 

This  is  the  operation  of  choice  for  most  surgeon.s 


136      THE   T  BE  AT  ME  NT  OF  FRACTURES 


in  th€  vast  majority  of  cases  :  esquillectoniy  liniited 
and  prudent,  is  the  expression  they  always  use,  just 
sufficient  to  avoid  the  incidence  of  acute  sepsis.  Tn  the 
favourable  cases  just  described,  when  the  injury  is 
very  limited,  such  as  the  detachment  of  the  olecranon 

or  of  the  internal  epicon- 
dyle.  it  is  capable,  when 
done  early,  of  giving  an 
excellent  result 

But  when  the  damage 
is  more  extensive,  when 
a  fracture  through  the 
epiphysis  is  concerned,  it 
is  almost  always  insuffi- 
cient to  ensure  complete 
disinfection  of  the  joint. 
Furthermore,  it  interferes 
with  the  functions  of  the 
joint  either  by  ankylosis 
or  by  loss  of  proper  move- 
ment later.  If  any  in- 
fection remains,  ankylosis 
is  inevitable,  since  it 
causes  the  cartilage  to 
ulcerate  and  leaves  the 
inflamed  bony  surfaces  in 
close  contact.  As  to  the 
loss  of  the  normal  move- 
ments, this  is  a  necessary 
consequence  of  limited 
unilateral  esquillectomy. 
Ablation  of  one  of  the 
condyles  of  the  humerus 
destroys  the  statics  of  the  joint  and  subsequently 
interferes  with  its  dynamics  :  the  elbow  deviates  to 
one  side,  and  the  final  result  is  bad, 

Tn  more  severe  fractures  with  extensive  Assuring, 
which  are  in  fact  the  cases  of  medium  gravity,  arthro- 


FiG.  25. — Fracture  of  the  ole- 
cranon by  shell-splinter,  treated 
by  simple  immobilisation  and 
antiseptic  lavage.  No  operative 
intervention.  Recovery  with 
ankylosis  of  the  elbow.  Patient 
seen  in  consultation  five  months 
after  the  injury  to  decide  upon 
the  utility  of  resection,  which 
has  been  rejected  as  useless,  con- 
sidering the  angle  of  the  anky- 
losis and  the  profession  of  the 
patient. 


THE   ELBOW 


137 


tomy  and  esquillectomy  fail  to  get  rid  of  the  septic 
complications  that  they  are  incapable  of  preventing. 
In  a  joint  as  close-fitting 
as  that  of  the  elbow, 
simple  incision,  even 
when  followed  by  })er- 
fect  immobility,  is  less 
able  than  in  the  case  of 
the  other  joints  to  pre- 
vent or  stay  the  develop- 
ment of  acute  articular 
osteitis,  which,  even  in 
the  most  favourable 
cases,  tends  to  become 
chronic.  It  is  powerless 
to  prevent  the  necrosis 
of  adherent  fragments 
of  bone,  whose  vitality 
seemed  sufficient  at  the 
moment  of  intervention, 
but  which  sepsis  has  con- 
verted into  sequestra  in- 
carcerated in  the  anky- 
losed  mass. 

Long  after  an  apparent 
cure,  the  elbow  remains 
exposed  to  relapses  of 
inflammation  in  the  form 
of  intra-articular  ab- 
scesses and  obstinate 
sinuses,  which  can  only 
be  cured  by  a  late  re- 
section. But  resection 
at  this  stage  is  a  me- 
diocre operation  viewed 
from  the  standpoint   of 

function.     Performed  upon  chronically  inflamed  bones, 
its  results   are   uncertain  ;   1  allude  to  the   difficulty 


Fig.  26. — Fracture  of  the  ole- 
cranon by  shell-splinter  treated 
by  incision  of  the  soft  parts,  im- 
mobilisation, and  antiseptic  lavage. 
Recovery  obtained  in  eight 
months  with  ankylosis  of  the 
elbow.  This  case  was  particularly 
well  .suited  to  primary  resection  : 
recovery  would  have  resulted 
sooner  and  probably  with  satis- 
factory movement.  The  patient 
seen  in  consultation  nine  months 
after  the  injury,  before  his  dis- 
charge, submitted  to  resection 
which  has  given  a  good  result, 
Jjut  the  power  of  active  move- 
ment is  limited  by  induration  of 
the  muscles  caused  by  prolonged 
suppuration  and  the  methods  of 
drainage. 


138    THE  TREATMENT  OF  FRACTURED 

of  avoiding  ankylosis.  On  the  other  hand,  even 
if  passive  movement  can  be  obtained,  there  is  serious 
difficulty  in  regaining  satisfactory  active  movement, 
which  after  all  is  the  only  useful  one.  The  result 
usually  depends  upon  the  condition  of  the  muscles, 
which  is  generally  deplorable  in  the  cases  under  con- 
sideration :  they  are  sclerosed  and  atrophied  with 
indurated  and  adherent  aponeurotic  scar  tissue,  and 
it  is  very  difficult  to  restore  muscular  contractility 
and  anything  like  the  normal  suppleness  of  the  tissues. 

To  sum  up,  the  object  sought  by  means  of  arthro- 
tomy  and  esquillectomy  can  be  attained  much  more 
easily  by  primary  resection,  which  is  the  operation  of 
choice  for  limited  injuries,  and  which  alone  is  suited 
for  the  cases  in  which  there  is  great  destruction  of 
the  elbow,  and  which  we  are  now  going  to  consider. 

2.  SuB-PERiosTEAL  RESECTION. — Immediate  resec- 
tion is,  strictly  speaking,  the  type  of  the  clearing 
operative  procedure  applicable  to  all  injuries  that  are 
not  simple  parietal  fractures  or  bullet  wounds  with 
punctiform  openings,  and  to  all  cases  in  which  the 
fracture  has  upset  the  mechanism  of  the  joint.  Per- 
formed in  the  first  few  hours  or  even  days  after  the 
accident,  it  permits  the  removal  of  organic  foreign 
bodies,  fragments  of  clothing,  missiles,  and  free 
splinters  of  bone,  together  with  any  other  structures 
that  are  dead  or  likely  to  die.  It  makes  a  wound  so 
regular  and  clean  that  no  sepsis  can  develop  in  it ; 
it  is  really  prophylactic  against  infection,  and  it 
banishes  the  fear  of  serious  complications.  Its  after- 
results  are  very  simple,  if  they  are  looked  after  with 
ordinary  care  ;  there  is  rapid  recovery  of  almost  the 
full  range  of  movement  of  the  joint,  after  an  aseptic 
healing,  and  since  the  patients  are  men  in  full  physical 
vigour,  with  intact  muscles,  an  active  new  joint  is 
almost  always  obtained  with  really  excellent  functional 
efficiency. 

If  the  after-care  is  not  what  it  should  be,  ankylosis 


THE  ELBOW  139 

results  ;  the  very  result  aimed  at  by  the  so-called 
consei-vative  operations  of  arthrotomy  and  esquil- 
lectomy.  Thus,  the  bad  result  of  a  resection  is  at 
least  equal  to  the  good  result  of  an  esquillectomy. 
Indeed  it  is  generally  better,  for  the  ankylosis  which 
is  obtained  after  resection  results  from  fusion  of  two 
healthy  bones,  and  therefore  the  patient  is  not  exposed 
to  the  later  complications  which  have  been  noticed 
after  arthrotomy. 

Resection  has,  however,  been  much  opposed  and 
numerous  rej^roaches  have  been  levelled  at  it,  none 
of  which  are  justified. 

(a)  To  begin  with,  it  is  said  that  resection  is  not 
necessary,  since  injuries  of  the  elbow  are  mild,  and 
heal  easily  after  arthrotomy.  This  opinion  has  only 
been  pronounced  hitherto  by  surgeons  at  the  base 
who,  contrary  to  what  they  imagine,  have  only  seen 
very  selected  cases.  It  is  well  to  repeat  here  that  it 
is  a  long  way  from  the  line  of  fire  to  a  base  hospital, 
and  at  these  latter  only  those  patients  arrive  who 
have  been  able  to  stand  at  least  two  or  three  days' 
journey  without  developing  serious  infective  com- 
l^lications.  Between  the  wounded  in  the  front  line 
and  those  who  reach  the  base  there  is  an  enormous 
difference.  Those  who  talk  of  the  mildness  of  elbow . 
injuries  do  not  realise  the  number  of  amputations 
that  these  injuries  necessitate  at  the  front,  especially 
when  resection  is  not  boldly  put  into  practice.  And 
even  these  figures  would  only  give  an  inexact  impres- 
sion, for  it  would  not  include  deaths.  It  is  not  suffi- 
ciently realised  that  tWo-thirds  of  the  injuries  to  the 
elbow  caused  by  shell-splinters  or  the  explosive  effects 
of  bullets  are  dangerous  to  life.  Delay  in  freely 
clearing  out  the  wound  is  heavily  paid  for.  Gas 
gangrene,  acute  sepsis,  arthritis  and  articular  osteitis, 
lead  to  early  secondary  amputation,  which  the  sujd- 
porters  of  the  supposed  mildness  of  elbow  injuries  do 
not   bear .  in   mind,   probably   because   they   are   not 


140     THE   TREATMENT  OF  FRACTURES 

aware  of  it  :  nevertheless  this  fact  has  to  be  reckoned 
with.  At  almost  every  medical  board  at  which  we 
see  cases  that  have  had  amputation  of  the  arm,  there 
are  one  or  two  which  have  been  done  for  fractures 
involving  the  elbow-joint.  The  case-sheet  reads  : 
"  Gas  gangrene,  or  septicaemia,  occurring  at  the  end 
of  three  or  four  days."  That  is  the  condition,  but 
primarily  it  arose  from  a  fracture  of  the  joint,  and 
resection  would  certainly  have  avoided  both  the  com- 
plication and  the  amputation. 

(6)  It  is  also  said  that  esquillectomy  is  generally 
sufficient,  and  that  it  is  a  less  wasteful  operation  than 
resection.  It  is  perfectly  true  that  it  is  sufficient  when 
the  fracture  is  limited  in  extent  and  confined  to  a 
single  bone.  But  the  avoidance  of  sepsis  at  a  small 
cost  does  not  constitute  economy.  The  economy  we 
require  is  not  so  much  concerned  with  the  bone  as  with 
the  function  of  the  joint.  Now,  ablation  of  a  condyle 
of  the  humerus,  or  of  a  part  of  the  ulna,  certainly 
gives  a  deplorable  functional  result.  The  forearm  is 
in  bad  position  and  either  varus  or  valgus  occurs.  The 
only  way  of  procuring  a  good  functional  result  with 
certainty  in  this  kind  of  case  is  to  perform  a  typical 
resection.  I  will  return  to  this  point  later.  When 
two  bones  are  fractured,  esquillectomy  is  only  appar- 
ently economical.  It  sacrifices  less  in  width,  but  just 
as  much  in  length  ;  and  it  is  this  latter  point  alone 
which  is  important  from  the  point  of  view  of  the 
function  of  the  joint. 

(c)  It  is  also  objected  that  resection  of  the  elbow  is 
more  difficult  than  arthrotomy,  and  since  war  opera- 
tions are  performed  by  surgeons  who  have  no  great 
experience  of  bone  surgery,  they  should  preferably 
be  simple. 

I  confess  that  I  cannot  understand  this  reasoning. 
There  are  not  two  kinds  of  surgery,  that  of  the  ignorant 
practitioner  and  that  of  the  experienced  :  the  latter 
alone  ought  to  be  the  operators  at  the  front.     It  is 


THE  ELBOW  141 

easier  to  perform  a  resection  at  the  elbow  than  to  do 
a  laparotomy  or  tie  some  large  vessel.  The  surgeon 
engaged  in  the  difficult  surgery  at  the  front  ought  to  he 
capable  of  doing  a  siih- periosteal  resection  of  the  elbow  ; 
if  not,  how,  I  ask,  can  he  perform  his  daily  tasks  ?  It 
is  his  right  and  his  duty  to  do  the  operation  which 
appears  best  from  the  point  of  view  of  the  preservation 
of  life  and  recovery  of  function. 

[d)  It  is  further  stated  that  in  times  of  stress  it  is 
impossible  to  supervise  the  post-operative  stages  of  a 
resection;  and  that  this  is  vital.  As  a  matter  of  fact 
a  resection  of  the  elbow  is  much  more  easy  to  look 
after  than  an  esquillectomy,  which  is  always  liable  to 
the  onset  of  infection.  A  resection  runs  an  aseptic 
course,  and  as  a  general  rule  there  is  no  need  for 
further  operation,  while  arthrotomies  which  suppurate 
frequently  require  fresh  incisions  and  always  call  for 
daily  dressings.  In  a  front-line  ambulance  a  case  of 
resection  gives  much  less  anxiety  than  an  arthrotomy . 
And  later  on,  when  the  time  comes  for  daily  movements, 
it  is  very  easy  to  spare  two  or  three  minutes  daily  to 
perform  them.  I  have  always  found  time  to  do  so 
while  in  charge  of  a  large  ambulance  at  the  front ; 
at  a  base  hospital  it  is  simply  a  matter  of  willingness 
to  do  it,  and  of  organisation. 

(e)  Another  objection  is  that  resection  is  not 
economical,  because  it  leads  to  the  removal  of  frag- 
ments, which  might  have  been  preserved  by  a  waiting 
policy,  and  the  preservation  of  which  would  have 
diminished  the  loss  of  substance. 

To  me  this  appears  ridiculous.  A  properly  per- 
formed resection  does  not  mean  a  final  loss  of  bone  ; 
if  it  leads  to  large  sacrifices,  it  is  because  the  damage 
is  excessive.  I  do  not  understand  w^hy  a  T-shaped 
fracture  of  the  humerus  with  injury  to  one  of  the  bones 
of  the  forearm,  which  is  a  frequent  condition,  should 
necessitate  too  extended  a  resection.  Out  of  eighteen 
cases  of  primai-y  resection,  T  have  never  been  led  to 


142     THE  TREATMENT  OF  FRACTURES 


remove  more  than  was  necessary.  The  whole  point 
is  to  know  if  the  operation  will  give  a  good  functional 
result.  Then,  if  it  is  correctly  performed,  that  is, 
strictly  sub-periosteally,  and  if  the  after-treatment  is 
efficient,  it  always  leads  to  a  satisfactory  recovery  of 

function.  There  is 
no  need  to  quibble 
with  words  :  when 
a  fracture  of  the 
epiphysis  is  in 
question,  the  most 
economical  opera- 
tion is  a  typical 
resection  and  not 
esquillectomy  ;  be- 
cause the  former, 
by  sacrificing  more 
in  width,  but  not 
in  length,  is  defi- 
nitely much  more 
preservative  o  f 
function.  When 
there  has  been  ex- 
tensive destruction 
of  shaft  and  epiphy- 
sis it  is  more  eco- 
nomical than  any 
other  operation,  be- 
cause it  will  save 
the  limb,  its  func- 
tions, and,  some- 
times, life  itself.  In 
eighteen  primary 
resections  I  am  con- 
vinced that  I  have  avoided  at  least  four  if  not  six 
amputations  of  the  arm  and  one  disarticulation  at  the 
shoulder.  Thanks  to  primary  resection  at  the  front, 
I  have  not  amputated  once  for  fracture  of  the  elbow, 


Fig.  27. — Result  of  primary  resection 
for  explosive  destruction  of  the  hiimenis 
and  ulna  by  shell-.splinter.  No  feverish 
symptoms.  Complete  cicatrisation  in 
thirty-five  days  ;  perfect  restoration  of 
function ;  complete  active  extension ; 
flexion,  pronation,  and  supination  nor- 
mal. The  patient  can  carry  15  kilos 
with  the  arm  raised  and  can  pull  150 
kilos  with  the  hand  of  the  injured  side. 
Radiograph  taken  at  the  end  of  eight 
months  ;  the  regularity  of  the  contour 
of  the  bones  is  noticeable.  Compare 
this  figure  with  figs.  7,  8,  and  9,  which 
relate  to  the  same  case  :  there  is  no  ex- 
cessive periosteal  bony  new  growth,  as 
in  the  secondary  or  later  cases  of  resec- 
tion shown  in  figs.  33  and  47. 


THE  ELBOW 


143 


iuid  1  have  not  lost  a  single  case.  1  think,  therefore, 
that  I  have  a  right  to  say  that  resection  is  an 
economical  operation. 

(/)  The  most  important  objection  is  that  resection 
gives  bad  functional  results,  because  it  leads  to  a  fiail- 
limb,  which  is  of  much  less  value  than  an  ankylosed 
joint.  Ankylosis  in  good  position  is  undoubtedly  more 
useful  than  a  flail-limb.  But  even 
the  latter  with  a  normal  hand  is 
more  useful  than  the  finest  artificial 
limb  ;  moreover,  it  must  be  ad- 
mitted that  a  resection  that  has 
called  for  enough  loss  of  tissue  to 
cause  a  flail-elbow  in  all  probability 
saved  the  limb  from  amputation. 
In  an  operation  such  as  resection  of 
the  elbow  bad  results  can  only  be 
due  to  one  of  three  causes :  too 
great  sacrifice  of  bone,  necessitated 
by  the  extent  of  the  injury  (more 
than  2|  inches  of  the  bones  forming 
the  joint),  bad  operative  technique, 
or  faulty  after-treatment ;  of  these 
the  two  last  points  are  the  most 
important. 

Oilier  obtained  satisfactory  re- 
covery of  function  in  patients  from 
whom  he  removed  four  inches  of 
the  bone,  and,  like  others,  I  have 
personally  seen  similar  cases.  It 
can  be  affirmed,  then,  that  if  the 
results  are  bad,  if  flail-limbs  are 
found  at  the  base  hospitals,  one  of 
two  things  has  happened.  Either  the  operator  has 
been  confronted  with  considerable  injuries,  in  which 
case  he  has  been  well-advised  in  performing  resec- 
tion, since  the  operation  has  in  spite  of  all  been 
conservative  ;   or  the   injuries  were   limited  but  the 


Fig.  28.— The 
same  patient  as  fig. 
27.  Radiograph  of 
extension  in  profile  : 
it  is  noticeable  that 
the  forearm  is 
flexed  on  the  front 
of  the  lower  ex- 
tremity of  the  hu- 
merus. 


144     THE   TREATMENT   OF   FRACTURES 

technique  was  bad,  in  which  case  tlie  fault  is  not 
that  of  the  operation,  but  of  the  operatoi"  himself, 
or  the  surgeon  who  directed  the  after-treatment. 
These  last  factors,  bad  technique  and  bad  supervision 
of  the  after-treatment,  are  undoubtedly  the  most 
frequent  causes  of  failure.  Whatever  indeed  may  be 
the  extent  of  the  damage,  strictly  sub-periosteal  opera- 
tion in  a  young  man  with  powerful   muscles  ought 


■\ 

/T^ 

/ 

£^ 

2 

jyyU-=.^ 

^ 

1/     ^ 

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II  ■ 

Fig.  29. — Functional  result  obtained  by  primary  resection  of 
the  elbow  :  photograph  taken  six  months  after  the  injury.  I'he 
patient  has  been  shown  to  the  Societe  de  Chirurgie.  The  radio- 
graphs 7,  8,  9,  27,  and  28  relate  to  this  case. 

always  to  give  a  satisfactory  result,  and  ought  not  to 
end  in  a  flail-joint.  This  flail-elbow,  without  the  least 
power  of  movement,  is  primarily  due  to  complete 
muscular  insufficiency.  When  a  primary  resection  is 
performed,  the  muscles  are  vigorous  and  strong, 
nothing  has  atrophied  them  ;  when  they  contract, 
they  bring  the  newly  formed  articular  surfaces  into 
close  contact  with  one  another  ;  playing  the  role  of 
ligaments  they  articulate  the  new  joint,  so  to  speak, 
and  allow  it  to  work  freely  and  with  ])jecision,  even  if 
the  resection  has  })een  an  extensive  one.  Among 
the  eighteen  j^atients  u])on  whom  1  have  done  early 
resection,  a  large  pro])ortion  have  had  considerable 
amounts  of  bone  removed  ;  none  have  got  a  powerless 
arm  ;  and  in  all  of  them,  thanks  to  their  muscles,  tlie 
active  movements  of  the  new  joint  have  been  good. 


THE  ELBOW 


145 


One  of  them,  after  losing  four  inches  of  bone  following 
destruction  of  the  elbow  (figs.  30  and  31),  can  carry 
more  than  10  kilos  (20  lb.)  with  his  arm  extended; 
another  draws  a  hand-cart  loaded  with  160  kilos  with 
the  hand  of  the  resected  limb.     It  is  interesting  to 


Fig.  30. — Early  secondary  resec- 
tion (fifth  day)  for  explosive 
destruction  of  the  elbow.  The 
splinters  having  been  removed  sub- 
periosteally,  the  end  of  the  shaft  of 
the  humerus  has  been  cut  straight 
through  with  the  saw.  Radiograph 
taken  twenty  days  after  operation. 
Complete  recovery  in  sixty- five  days 
after  the  operation. 


Fig.  31. — Radiograph  of 
the  same  elbow  three 
months  after  resection, 
showing  the  periosteal  new 
formation  on  the  bony  ex- 
tremities. After  a  year,  the 
l^atient,  in  spite  of  the  ex- 
tensive loss  of  bubstance, 
has  a  perfect  restoration  of 
flexion,  extension,  pronation, 
and  supination. 


note  that  this  man  was  forty-two  years  of  age  when 
the  resection  was  done,  which  proves  that,  from  the 
point  of  view  of  recovery  of  functional  power,  age  is 
not  so  important  as  is  imagined.  In  consequence  of 
what  I  have  seen,  I  think  that  the  flail-elbow  is  due 
to  a  faulty  technique,  or  to  an  absolute  want  of  x^ost- 


146    THE  TREATMENT  OF  FRACTURED 

operative  attention  ;  it  is  met  with  in  consequence  of 
its  being  forgotten  that  the  patient  requires  super- 
vision after  resection,  and  should  not  be  left  to  his 
own  resources  during  the  months  that  he  carries  his 

arm  in  a  splint. 

In  conclusion,  resection  is  an  excellent  operation 
when  one  knows  how  to  do  it,  and  when  one  takes 
the  trouble  to  direct  the  after-treatment  according  to 
the  principles  of  orthopaedics  and  physiology.  It 
should  be  done  at  once  for  all  severe  fractures,  because 
it  is  the  best  method,  if  not  the  only  one,  of  prevent- 
ing or  checking  infection,  and  thus  avoiding  ampu- 
tation ;  and  in  wounds  of  moderate  gravity,  because 
it  is  the  only  way  of  preventing  ankylosis  and  of  pre- 
serving the  normal  mobility  of  the  joint. 

Moreover,  primary  resection  is  to  be  preferred, 
because  it  does  away  with  infection,  which  would 
injuriously  affect  the  progressive  regeneration  of  bone, 
and  because  it  permits  of  complete  muscular  integrity, 
which  ensures  a  good  functional  result.  After  a 
primary  resection,  the  extremities  of  the  bones  are 
restored  with  regular,  smooth,  and  clean  outlines  and 
mobility  is  much  more  easily  obtained  than  after 
secondary  resection  in  which  the  periosteum,  inSamed 
and  feeble,  proliferates  so  wildly  that  the  post- opera- 
tive treatment  becomes  extremely  difficult. 

The  physiology  of  the  joint  corresponds  with  the 
anatomical  condition,  and  this  can  be  studied  by 
radiography.  I  have  examined  a  dozen  resections 
under  the  screen  :  the  play  of  the  joints  resulting  from 
aseptic  resection  is  infinitely  more  supple,  more  varied 
and  delicate,  than  it  is  in  those  in  which  resection  is 
done  when  sepsis  is  present.  The  gliding  of  the  bony 
surfaces  is  softer  and  more  regular  and  is  effected 
in  one  of  three  ways  :  sometimes  the  extremities  of 
the  bones  of  the  forearm  move  in  the  normal  plane, 
end  to  end  with  the  humerus  (figs.  30  and  31)  ;  some- 
times they  pass  in  front  of  the  lower  extremity  of  the 


THE  ELBOW 


147 


humerus,  which  is  hollowed  out  to  form  a  cup  like 
a  reversed  olecranon  fossa  (figs.  27,  28)  ;  and  at 
other  times  the  bones  of  the  forearm  slide  a  little 
backwards,  and  when  flexion  occurs  are  almost  in 
contact  with  the  jjosterior  surface  of  the  humerus. 
With  each  of  these  types,  of  which  the  two  former  are 
the  most  frequent, 
the  functional  ap- 
pearance is  equally 
satisfactory. 
Briefly,  the  radio- 
scopic  study  of  new 
joints  at  the  elbow 
demonstrates  that 
after  a  correct  and 
early  operation,  the 
physiological  r  e  - 
storation  of  the 
joint  can  be  reason- 
ably counted  upon  ; 
which  is  one  more 
argument  in  favour 
of  primary  resec- 
tion. 

This  operation 
has  only  one  contra- 
indication, viz.  the 
presence  of  a  frac- 
ture of  the  shaft  of 
the  humerus,  or  of 
the  bones  of  the 
forearm  about  their 

centre.  In  these  cases  it  is  better  to  wait  for  the 
consolidation  of  the  fracture  and  then  to  perform  a 
secondary  resection.  This  delayed  operation  has 
yielded  a  very  good  functional  result  in  my  hands 
(figs.  32,  33). 

3.  Amputation. — There  is  no  indication  for  primary 


FiG.  32. — Fracture  at  the  middle 
third  of  the  humerus  and  severe  fracture 
of  the  elbow.  Resection  delayed  till 
the  seventy-second  day,  after  union  of 
the  fracture  of  the  shaft.  Radiograph 
taken  one  month  after  resection. 


148      THE  TREATMENT  OF  FRACTURES 


Fig.  33. — The  same  patient 
as  in  tig.  32  :  result  of  a  de- 
layed resection.  Radiograph 
at  the  second  month.  The 
fracture  of  the  shaft  is  united ; 
there  is  a  mass  of  new  bone  at 
the  epiphysis  ;  the  functional 
result  is  good  ;  but  there  is 
some  difficulty  in  obtaining 
satisfactory  flexion  because  of 
the  Ijony  mass  at  the  front  of 
the  joint.  However,  three 
months  after  resection  active 
flexion  reached  90  degrees,  and 
extension  is  complete,  but 
pronation  and  supination  are 
slightly  limited. 


amputation  in  fractures  of 
the  elbow  when  the  vessels 
and  nerves  are  not  severed, 
extensive'  resection  being 
sufficient  even  in  the  most 
complex  fractures.  Neither 
is  it  indicated  as  a  secon- 
dary measure,  early  re- 
section preventing  all  the 
complications  which  might 
make  it  necessary. 

The  indications  for  opera- 
tion in  fractures  of  the 
elbow  can  be  summed  up 
as  follows : 

Ablation  and  immobili- 
sation in  plaster  for  punc- 
tiform  bullet  wounds. 
Limited  arthrotomy  and 
esquillectomy  for  parietal 
fractures  and  cases  of  can- 
cellous crushing  by  a  mis- 
sile embedded  in  the  bone. 
Primary  resection  for  all 
fractures  into  the  joint, 
and  for  all  bony  injuries 
due  to  explosive  injuries. 

Secondary  resection  for 
fractures  of  the  elbow 
complicated  with  fracture 
of  the  shaft,  above  or 
below  the  articular  injury. 
There  is  no  indication  for 
amputation  provided  that 


the  vessels  and  most  of  the  nerves  are  intact. 


THE  ELBOW  149 

in.   Operative  Technique 

ia)  Arthrotomy  ought  to  be  performed  by  two 
vertical  incisions  passing  as  far  as  possible,  one  in 
the  space  between  the  supinator  longus  and  the  outer 
head  of  the  triceps,  descending  thence  towards  the  base 
of  the  olecranon  ;  the  other  over  the  internal  condyle. 
There  should  be  no  hesitation  to  make  the  incision  free, 
and  in  case  of  need  to  convert  it  into  the  incision  for 
resection  indicated  below.  Esquillectomy  should  be 
done  with  the  rugine,  followed  by  curetting  the  can- 
cellous bone,  so  as  to  remove  all  suspicious  tissue.  The 
arm  should  be  flexed  so  as  to  make  the  incision  gape 
and  give  more  room .  The  wound  is  plugged  with  aseptic 
gauze,  and  the  limb  carefully  immobilised.  For  the 
first  few  days  it  is  put  in  a  well-padded  wire  splint, 
moulded  to  the  limb  and  with  the  wrist  extended 
and  the  fingers  free. 

(&)  Resection  ought  to  be  done  according  to  very 
precise  rules,  all  of  which  are  important,  though 
scarcely  mentioned  by  the  treatises  on  operative 
surgery.  The  principal  point  is  to  aim  at  following 
the  classical  steps  of  the  operation  in  every  particu- 
lar. There  should  be  no  departure  from  the  regular 
method  in  consequence  of  the  existence  of  wounds, 
either  of  entrance  or  exit.  From  start  to  finish  the 
operation  should  be  carried  out  as  if  they  did  not 
exist.  It  is  needless  to  apply  an  Esmarch's  bandage, 
and  it  is  better  to  arrest  bleeding  as  one  goes  along. 

The  Incision. — Having  tried  all  sorts  of  incisions, 
I  advise  the  angular  extero-posterior  or  bayonet- 
shaped  incision  of  Oilier,  which  gives  plenty  of  room 
and  does  not  divide  muscle.  The  median-posterior  and 
the  two  lateral  incisions  gape  at  the  end  of  the  opera- 
tion and  form  button-holes  ;  they  are  liable  to  cause 
retention  of  the  discharges  and  do  not  give  sufiicient 
drainage.  The  bayonet-shaped  incision  commences  two 
inches  and  a  half  above  the  projection  of  the  external 


/5()     THE   TREATMENT  OF  FRACTURES 


condyle  and  runs  along  the  postero-external  edge  of 
the  humerus ;  thence  it  is  directed  obliquely  down- 
wards and  inwards  to  the  base  of  the  olecranon,  where 
it  bends  sharply  to  follow  the  posterior  edge  of  the 
ulna  for  two  inches  ;  it  does  not  divide  any  muscle, 
and  leaves  the  fibres  of  the  triceps  untouched. 

Denudation  of  the  Bones. — When  the  incision  has 
reached  the  bone,  the  knife  is  discarded 
for  the  sharp  rugine,  which  alone  is 
capable  of  doing,  as  it  should  be  done, 
the  first,  and,  from  the  point  of  view  of 
the  future,  the  most  important  part, 
of  the  operation,  viz.  the  denudation  of 
the  olecranon  and  the  detachment 
of  the  insertion  of  the  triceps.  By 
degrees,  keeping  close  to  the  bone  and 
actually  cutting  into  the  bony  tissue, 
the  rugine  completely  detaches  the 
tendon  and  the  periosteum.  The  de- 
nudation of  the  internal  condyle  of 
the  humerus  and  the  liberation  of  the 
ulnar  nerve  are  then  undertaken;  this 
is  neither  difficult  nor  dangerous  if  the 
rugine  is  well  under  control.  The 
instrument  must  be  kept  scrupulously  in  contact 
with  the  bone  and  the  groove  between  the  epicondyle 
and  the  olecranon  carefully  cleared. 

The  rugine  will  ere  this  have  met  with  sphnters 
and  bony  debris,  and  the  operation  cannot  theretore 
correspond  to  any  written  description.  The  entire 
attention  should  be  given  to  clearing  the  joint  of 
detached  fragments  of  bone.  Nothing  need  be  torn 
away  :  each  spUnter  of  any  size  is  held  with  forceps 
while  the  rugine  strips  off  its  periosteum.  After  frag- 
ments have  been  removed,  the  systematic  freeing  of 
the  extremities  of  the  bones  is  undertaken  :  first,  on 
the  inner  side,  until  the  tip  of  the  epitrochlea  has 
been  cleared  well  down  on  to  the  ulna,  detaching  the 


Fig.  3  4.— 
Bay  onet-  shaped 
incisions  for  ac- 
cesa  to  the 
elbow- joint. 


THE  ELBOW 


151 


muscular  attachments  found  there  ;  and  then  the 
external  condyle  of  the  humerus  and  the  head  of 
the  radius.  Then  the  edges  of  the  sigmoid  cavity  of 
the  ulna  are  cleared,  and  the  insertion  of  the  brachialis 


Fig.    35.— Fracture     of     the  Fig.    38.— Radiograph   tak^n 

epiphysis  of  the  humerus  by  four  days  after  resection.  Cure 
shell-splinter.  Primary  resec-  rapid  with  recovery  of  active 
Wqxi^  flexion,     extension,     pronation, 

and  supination.     Complete  cica- 
trisation in  forty-five  days. 

anticus  into  the  coronoid 

process,  when  the  joint  can  be  held  wide  open  and 

the  bones  dislocated  backwards. 

When  the  nigine  has  freed  all  the  bony  surfaces  by 
detaching  the  muscular  insertions  without  cutting 
either  them  or  the  layer  of  pp^^osteum  to  which  they 
are  inserted,  the  time  has  arrived  for  making  the 
final  bone  sections.  This  is  regulated  by  the  Hne  of 
fracture  and  the  extent  of  the  bony  damage,  but  the 
object  should  be  to  make  the  section  of  the  humerus 
through  the  thickness  of  the  condyles,  or  just  above 


152     THE  TREATMENT  OF  FRACTURES 


them  where  the  shaft  commences  to  widen.  A  section 
through  the  epiphysis  just  l)elow  the  level  of  the  epi- 
condyle  is  the  best  if  it  can  be  managed. 

In  the  bones  of  the  forearm  the  section  ought  to  be 


Fig.  37. — Fracture  of  the  ex- 
tremities of  both  bones  of  the 
forearm  by  shell-spUnter,  treated 
at  the  front  by  incision  and  im- 
mobiUsation.  At  the  end  of 
fifteen  days  the  patient  reached 
me  in  a  condition  of  full  sepsis 
with  high  tejnperature  and  an 
enormous  elbow  -  joint.  The 
above  radiograph  was  taken  at 
that  moment.  Resection  of  the 
l)ones  of  the  forearm  was  per- 
formed forty  days  after  the 
injury. 


Fig.  38. — The  same  after  re- 
covery, two  months  later.  Ex- 
tension is  complete,  but  it  is 
only  effected  by  the  triceps  to 
45°  ;  flexion  complete  but  end- 
ing in  a  sudden  slipping  of  the 
ends  of  the  bones  of  the  forearm 
over  the  trochlea.  A  rather 
extensive  resection  of  the  epi- 
physis of  the  humerus  would 
doubtless  have  had  a  better  re- 
sult by  facilitating  the  adapta- 
tion of  tlie  epiphysis. 


carried  below  the  coronoid  and  through  the  neck  of 
the  radius. 

Very  often  the  articular  end  of  the  humerus  is  only 
fractured  on  one  side,  and  the  broken  fragment  carries 
with  it  a  thin  plate  of  the  shaft  :  enough  of  the  articular 
end  remains  on  the  sound  side  to  enable  the  section 
to  be  through  the  epiphysis,  which  is  sufficient  if  the 


THE  ELBOW  153 

periosteum  is  preserved,  for  this  latter  will  regenerate 
a  new  epiphysial  mass. 

Certain  fractures  may  necessitate  a  section  through 
the  shaft  :  the  procedure  should  then  be  confined  to 
removal  of  the  fragments  without  troubling  about  the 
shape  of  the  bony  extremities  remaining.  It  is  quite 
unnecessary  to  do  anything  for  the  fissures  which 
divide  the  shaft  longitudinally  as  if  it  were  split. 
After  the  removal  of  the  epiphysial  fragments,  every- 
thing is  perfectly  repaired  (see  figs.  7,  8,  and  9). 
At  most,  the  sharp  ends  may  be  smoothed  off  with 
cutting  pliers. 

When  the  fracture  separates  the  epiphysis  from 
the  shaft,  a  large  fragment  is  almost  always  found 
extending  along  the  latter  :  of  all  the  fragments  this 
alone  should  be  preserved  ;  the  others  are  carefully 
stripped  of  their  periosteum  and  removed.  In  this 
manner  we  preserve  in  an  aseptic  cavity  the  requisites 
for  periosteal  regeneration  of  bone,  the  completeness 
of  which  is  surprising.  The  lower  end  of  the  injured 
shaft  should  always  be  freed  and  cHpped  off,  for  there 
the  bone  is  of  a  reduced  vitality  and  ea^ly  necroses. 

But  if  it  is  necessary  to  be  sparing  in  the  removal 
of  bone  on  the  diaphysial  side  of  the  epiphysis,  it 
must  be  reaUsed  that  economy,  as  appUed  to  resection 
in  fractures  locaUsed  to  the  epiphysis,  is  a  mistake 
from  the  point  of  view  of  the  future  function  of  the 
injured  joint.  The  results  of  a  very  limited  removal 
are  much  less  satisfactory  than  those  of  free  resection  : 
when  the  articular  surfaces  can  come  into  close  apposi- 
tion immediately,  all  the  benefit  of  resection  as  regards 
drainage  is  lost,  and  the  functional  result  is  endan- 
gered by  the  risks  of  ankylosis. 

Moreover,  if  the  movements  of  pronation  and  supina- 
tion are  to  be  obtained,  complete  removal  of  the  head 
of  the  radius  is  essential.  This  is  a  view  of  the  ques- 
tion that  the  partisans  of  hemi-resection  do  nbt  take 
into    consideration.     Cases    in    which    supination    is 


154    THE   TREATMENT  OF  FRACTURES 

retained  after  that  operation  are  very  rare  indeed  ; 
I  have  never  seen  any  myself. 

In  a  word,  except  in  fractures  where  the  loss  of 
bone,  shaft,  and  epiphysis  in  one  of  the  articular 
extremities  is  much  too  considerable,  it  is  better  not 
to  adopt  hemi-resection  either  of  the  upper  or  lower 
half  of  the  joint  :  they  do  not  drain  well,  it  often 
becomes  necessary  to  complete  the  resection  some 
days  later,  and  besides,  the  functional  result  is  always 
inferior  to  that  obtained  by  complete  resection.  The 
reason  of  this  is  easy  to  discover  :  one  of  the  articular 
ends  being  still  covered  with  its  cartilage  cannot  be 
moulded  by  movement,  and  the  other  is  obliged  to 
adapt  itself  to  surfaces  which  are  too  complicated  for 
its  rudimentary  shape  ;  it  has  to  do  all  the  work  of 
forming  the  new  Joint  by  itself,  for  which  reason 
adaptation  is  more  difficult  and  less  perfect.  In  short, 
the  ideal  bone  section  is  similar  to  that  in  a  typical 
resection  for  tuberculous  disease. 

IV.   Alter-fteatment 

1.  After  Arthrotomy.— A  dressing  of  aseptic  gauze 
is  loosely  packed  between  the  bony  surfaces  round  a 
small  drainage  tube  inserted  in  the  openings  in  the 
capsule.  If  the  operation  has  been  done  early  and 
if  the  clearing  out  has  been  complete,  the  joint  ought 
not  to  suppurate,  and  through  and  through  drainage 
is  as  unnecessary  as  is  the  use  of  antiseptics  and  lavage. 

The  chief  desideratum  in  order  to  obtain  a  successful 
result  is  rigid  immobilisation. 

{a)  This,  however,  should  not  be  kept  up  for  long, 
if  all  goes  well :  at  the  end  of  a  week,  if  there  be 
neither  temperature,  pain,  nor  oozing,  movements 
should  be  commenced  and  attempts  made  to  restore 
the  free  play  of  the  joint. 

Consequently  it  is  needless  to  use  a  plaster  case 
if  the  patient  remains  under  observation.     The  Hmb 


THE  ELBOW  155 

should  be  placed  in  a  wire  or  aluminium  splint,  with 
the  elbow  at  a  right  angle  and  the  wrist  slightly  ex- 
tended ;  the  dressing  should  not  be  changed  till  the 
third  day  if  possible,  and  then  the  drainage  tube  should 
be  removed  without  touching  the  gauze. 

Two  days  later  the  gauze  should  be  removed  and 
replaced  by  a  smaller  quantity.  Two  days  later  the 
dressing  is  repeated  and  movement  begun,  after  which 
the  splint  is  reappUed. 

From  this  time  forward  regular  daily  movements  of 
the  joint  are  carried  out,  the  limb  being  kept  at  rest 
during  the  night  only. 

Recovery  occurs  in  one  or  two  months. 

(6)  If,  on  the  contrary,  the  exploratory  arthrotomy 
has  not  been  done  early  enough,  or  if  foreign  bodies, 
missiles,  or  spUnters  have  been  left  behind,  the  wound 
suppurates  freely  and  the  treatment  differs. 

Two  groups  of  cases  present  themselves  for  con- 
sideration. 

The  first  is  simply  one  of  profuse  suppuration 
without  constitutional  symptoms  ;  after  employing 
radiography  to  ascertain  the  cause  (missiles,  spHnters), 
typical  resection  is,  in  my  opinion,  the  indication,  but 
this  is  only  my  personal  opinion,  and  treatment  may  be 
limited  to  immobiHsation  in  a  plaster  casing  which 
will  permit  dressings  to  be  applied  without  moving  the 
joint  or  causing  pain.  There  is  no  call  to  try  to  pre- 
serve the  joint  movements,  for,  in  consequence  of  the 
suppuration,  the  joint  is  doomed  to  ankylosis.  Treat- 
ment may  be  limited  to  rigid  immobilisation,  avoiding 
all  movement  until  the  infection  has  disappeared. 

For  the  purpose  of  immobilisation  a  casing  should 
be  made  with  plaster  bandages  as  follows :  one  bandage 
encircling  the  middle  of  the  arm  ;  another  embracing 
the  forearm,  the  wrist,  and  the  slightly  extended  hand  ; 
two  metal  brackets  to  form  a  bridge,  one  on  each 
side  and  a  little  to  the  front.  This  plaster  casing  is 
easy  to  make  and  to  supervise,  and  fulfils  the  neces- 


156    THE  TREATMENT  OF  FRACTURES 

sary  purposes.  Tbe  forearm  should  be  flexed  at  a 
right  angle  in  the  semi-pronated  position,  thumb 
upwards. 

If  suppuration  of  the  joint  is  accompanied  by 
constitutional  symptoms,  if  there  is  a  missile  in  the 
joint  or  splinters  that  requires  to  be  removed,  the 
best  plan  is  to  perform  immediate  resection.  This  is 
done  in  the  manner  indicated  above  :  if  the  wound 
is  left  wide  open,  it  will  quickly  become  aseptic,  and 
generally  movements  can  be  commenced  at  the  end 
of  a  week  or  a  fortnight  after  suppuration  has  ceased 
and  the  patient  is  free  from  fever.  When  the  treat- 
ment can  be  well  carried  out,  these  "  intra-febrile  " 
resections  give  good  results.  I  have  done  eight  for 
war- wounds  and  have  obtained  seven  good  results,  and 
one  moderate  one ;  the  latter  is  getting  better  with 
the  aid  of  massage,  hot  baths,  and  daily  exercise. 

2.  After  Resection :  Drjissing. — ^After  the  joint 
has  been  cleared  and  the  elbow  bent  at  an  acute  angle, 
the  wound  is  dressed  without  putting  ih  any  sutures. 
If  desired,  a  drainage  tube  can  be  passed  along  the 
track  of  the  missile  ;  it  goes  without  saying  that  this 
track  is  first  opened  up  and  cleaned  by  the  curette, 
and  that  all  debris  is  cHpped  away  carefully.  A  Httle 
aseptic  gauze  can  be  used  instead  of  a  drainage-tube. 
The  cavity  of  the  joint  is  stuffed  with  gauzTe,  without 
using  lavage  or  any  antiseptic.  An  absorbent  dressing 
is  placed  on  the  wound  and  the  elbow  is  immobilised 
in  a  wire  splint,  the  hand  being  slightly  raised  with  the 
thumb  upwards. 

As  the  wound  sometimes  oozes  a  good  deal,  it  is  best 
not  to  use  the  plaster  apparatus,  which  would  soon 
lose  its  shape  and  rigidity  owing  to  the  soaking  by 
the  discharges. 

Later  Treatment. — ^If  possible,  the  dressing  is  left 
untouched  for  seven  or  eight  days.  At  the  end  of 
that  time  its  removal  causes  less  haemorrhage  than  if 
it  were  done  sooner.     But  often  there  is  oozing  of 


THE  ELBOW  157 

blood-stained  serum  which  may  necessitate  its  earlier 
renewal.  In  that  case  the  outer  layers  only  are 
changed.  An  assistant  holds  the  Hmb  firmly,  with 
one  hand  on  the  humerus  and  the  other  supporting 
the  fore-arm,  and  upon  him  depends  the  amount  of 
pain  caused  by  the  dressing.  When  the  gauze  is 
removed  from  the  joint  cavity,  it  is  best  to  give  the 
patient  a  whiff  of  ethyl-chloride  ;  a  painless  dressing 
is  always  better  done.  Later  dressings^  will  be  done 
at  longer  intervals  if  one  does  not  commence  move- 
ment at  once. 

Sunlight  Therapy  or  Hot  Air. — ^Whenever  the 
weather  permits,  it  is  beneficial  to  expose  the  wound 
to  sunlight  from  the  fourth  or  fifth  day  onwards. 
Its  effects  are  marvellous.  A  quarter  of  an  hour's 
sitting  is  sufficient  to  rid  the  wound  of  all  the  small 
sloughs  which  are  seen  upon  it,  especially  at  the  first 
dressing,  and  to  give  it  a  healthy  red  appearance. 
After  three  or  four  sittings,  the  oozing  completely 
stops  and  heaUng  is  proceeding  rapidly.  The  muscles 
progress  admirably. 

If  sunlight  is  not  available,  hot  air  can  be  directed 
over  the  wound  for  five  minutes  at  a  time  :  the  effect 
is  less  rapid,  but  is  none  the  less  real. 

Movement. — ^As  soon  as  the  patient  has  a  normal 
temperature  and  is  free  from  pain,  the  surgeon  himself 
commences  active  movements,  gently  performing 
extension,  flexion,  pronation,  and  supination. 

The  aim  should  be  never  to  produce  pain  which  will 
put  the  patient  on  the  defensive.  After  a  few  min* . 
utes  of  movement  the  Hmb  is  replaced  in  the  spHnt. 
At  the  end  of  from  a  fortnight  to  three  weeks,  the 
spHrit  is  abandoned  and  the  Hmb  put  up  in  a  well- 
appHed  sHng.  After  that  the  patient  is  left  for  some 
hours  daily  without  the  sHng,  so  that  when  he  tries 
to  keep  his  forearm  raised  and  flexed,  he  is  bound 
to  attempt  some  sHght  active  movement.  Soon  he 
will  begin  to  gain  confidence  in  himself  and  to  work 


158     THE   TREAT3IENT  OF  FRACTURES 


at  it  himself.  Little  result  is  obtained  at  first,  but  by 
advising  him  to  try  several  times  in  the  course  of  each 
day,  progress  is  gradually  made. 

In  the  early  days  the  recovery  of  active  movements 
is  much  facilitated  by  compressing  with  the  fingers 
the  parts  immediately  above  the  elbow,  thus  giving 
more  fixity  to  the  ligaments  of  the  joint,  and  allowing 
muscular  action  to  be  more  easily  effected.     For  this 

purpose  I  am 
accustomed  to 
grasp  the  ante- 
rior surface  of 
the  arm  with 
both  hands,  as 
is  shown  in  fig. 
39.  The  i-esult 
is  immediate  : 
the  patient  be- 
gins to  flex  his 
forearm,  gains 
confidence,  and 
thenceforward 
works  with  a 
will. 

In  order  to 
practise  exten- 
sion it  is  abso- 
lutely necessary 
to  place  the 
arm  in  the  hori- 
zontal position, 
olecranon  up- 
wards, and  to  order  the  forearm  to  be  raised.  If 
that  exercise  is  not  carried  out,  the  triceps  does  not 
recover  its  contractile  power,  and  the  movement  of 
extension  remains  purely  passive  (see  fig.  40). 

It  goes  without  saying  that  massage  of  the  biceps 
and   triceps  should  be  commenced   early.     As  soon 


Fig.  39. — Method  of  commencing  active 
flexion.  The  fingers  are  pressed  over  the 
new  joint  and  give  more  power  to  the  liga- 
ments J  active  movement,  which  is  not  per- 
formed when  the  patient  is  left  to  himself, 
is  effected  to  the  extent  shown  in  the  second 
diagram  when  the  elbow  is  squeezed. 


THE  ELBOW 


159 


as  flexion  and 
active  extension 
reach  a  point  be- 
tween 60°  and  80°, 
all  passive  move- 
ment is  aban- 
doned and  t  b  e 
patient  does 
everything  for 
himself.  This 
daily  task  is  one 
o  f  patience  t  o 
which  he  lends 
himself  very 
readily  if  the  el- 
bow is  left  two  or 
three  hours  at  a 
time  exposed  to 
the  sun.  He  be- 
comes interested 
in  his  ann,  fol- 
lows its  progress 
attentively,  and 
learns  how  to 
work  his  joint. 
When  this  has 
happened,  one  can 
say  that  success 
is  assured ;  but 
even  then  one 
should  not  lose 
sight  of  him  :  his 
efforts  to  go  too 
fast  must  be 
curbed,  and  his 
desire  to  hurry 
must  be  re- 
strained.     He  must 


Fio.  40. — Method  of  making  the  patiexit 
perform  active  extension.  This  exercise 
wiJI  be  coi:nbined  with  massage  of  the  tri- 
ceps. Comparison  of  diagram  3  with  the 
two  upper  ones  shows  the  difference  be- 
tween active  extension  and  the  passive 
extension  occurring  upon  relaxation  of  the 
flexor  m,uscles.  The  photographs  were 
taken  from  a  case  which  had  been  resected 
three  months  previoiMly, 

learn  that  as  soon  as  his  move- 


UO     THE   TREATMENT   OF  FRACTURES 

ments  excite  the  least  pain  they  must  be  stopped,  and 
at  times  the  joint  must  be  immobiHsed  again  for  some 
days  so  that  it  may  be  at  rest.  When  a  patient  after 
resection  complains  of  cramps  in  the  muscle  of  the 
forearm,  it  is  because  there  is  periosteal  irritation 
which  tends  to  ossify  the  insertions  of  the  muscles 
and  demands  rest.  I  never  hesitate  under  these  cir- 
cumstances to  put  the  limb  in  plaster  for  a  week  : 
much  time  is  gained  by  actine  thus  on  the  first  warning. 

For  all  these  reasons  mobilisation  cannot  be  effected 
by  mechanical  means,  and  mechano-therapy  is  of 
absolutely  no  value  after  resection.  It  is  always  a 
disadvantage. 

In  a  word,  the  patient  himself  must  be  made  to 
collaborate  in  his  own  cure  by  calling  upon  his  good- 
will and  his  patience  ;  and  ankylosis  and  a  flail-elbow 
will  be  avoided  by  inculcating  these  precepts  in  him. 

V.   Evacuation  of  Patients  with  Elbow  Wounds 

Patients  wounded  in  the  elbow  ought  not  to  be 
evacuated  unless  they  have  a  bullet  wound  with 
punctiform  openings ;  all  the  others  should  be 
operated  upon  at  the  front  as  early  as  possible.  They 
should  only  be  evacuated  early  in  circumstances  of 
extreme  pressure,  and  then  ought  to  be  left  at  the 
first  surgical  rdai. 

Those  who  have  had  arthrotomy  done  for  slight 
injuries  can  be  evacuated  without  danger  after  the 
third  day  if  they  are  immobilised  in  a  travelling  plaster 
splint,  the  description  of  which  will  be  given  later  on. 
The  best  time  for  evacuation  for  them  is  the  eighth 
day,  after  the  first  attempts  at  movement  have  been 
made.  Those  who  have  been  resected  can  be  sent 
down  without  danger  towards  the  fourth  or  fifth  day. 
but  the  best  time  for  them  is  about  the  fifteenth  day, 
when  the  healing  process  has  made  good  progress. 

On  their  departure,  each  should  have  a  detailed 


THE  ELBOW 


161 


statement  indicating  the  stage  of  treatment  reached, 
whether  movements  have  been  commenced  or  not, 
and  giving  suggestions  upon  the  after-treatment. 

Travelling  Splints.— For  the  journey  the  limb  will 
be  immobilised  in  a  large  plaster  casing  covering  the 
posterior  a  n  d 
external  sur- 
faces of  t  h  e 
limb,  extending 
from  the  point 
of  the  shoulder 
to  the  lower  end 
of  the  meta- 
carpus. A  slip 
of  the  splint  is 
bent  down  into 
the  palm  be- 
tween  the 
thumb  and  the 
second  meta- 
carpal bone  to 
form  a  strap, 
which  fixes  the 
splint  and  pre- 
vents it  from 
slipping.  The 
casing  should 
only  cover  half 
the  circumference  of  the  limb.  It  should  be  made 
with  twelve  thicknesses  of  tarlatan.  A  cut  is  made 
just  opposite  the  elbow  to  allow  the  splint  to  adapt 
itself  to  the  flexed  joint.  The  limb  is  semi-pronated 
and  flexed  at  an  acute  angle,  with  the  thumb 
upwards.  The  plaster  splint  is  applied  to  the  limb 
by  a  gauze  bandage.  As  soon  as  the  plaster  is  dry, 
this  bandage  is  removed  for  fear  it  might  become  too 
tight,  and  is  replaced  b}^  another,  or  what  is  better, 
by  thiec  pieces  of  strapping,  one  on  the  arm,  one  on 


Fig.  41.— rXravelling-splint  for  wound  of 
shoulder.  Between,  the  dressings  this  easing 
can  be  used  for  permanent  immobilisation. 


162     THE  TREATMENT  OF  FRACTURES 

the  forearm,  and  one  at  the  level  of  the  hand.  Lastly, 
a  sling  is  applied  to  support  the  forearm  and  elbow. 
On  the  patient's  arrival  this  apparatus  is  removed  ; 
the  journey  should  not  exceed  forty-eight  hours' 
duration. 


VI.   Treatment  oS  Patients  seen  late  or  after  Evacuation 

1.  A  Patient  who  has  been  brought  in  after 

SOME  DELAY,  ARRIVES  AT  THE  AMBULANCE  AT  THE  END 

OF  24  OR  36  Hours. — The  elbow  is  swollen  and  pain- 
ful, and  sloughing  muscle  protrudes  from  the  wound, 
pouring  out  blood-stained  fluid.  Immediate  sub- 
periosteal resection  is  the  best  treatment ;  it  stops 
infection  at  once,  avoids  amputation,  and  ensures  rapid 
recovery  without  sinuses  or  muscular  atrophy.  This 
result  is  obtained  without  the  repeated  operations 
which  are  so  often  necessary  with  every  other  method 
of  treatment.  I  have  had  patients  completely  healed 
in  forty  days. 

The  after-treatment  ought  to  be  carried  out  on  the 
lines  laid  down  above. 

2.  A  Patient  is  evacuated  after  correct 
TREATMENT. — («)  A  case  in  which  immediate  arthrotomy 
has  been  done  for  parietal  fracture  or  removal  of  a  foreign 
body  in  contact  with  the  bone  heals  rapidly.  At  the 
end  of  a  fortnight,  immobilisation  is  abandoned  and 
movements  are  commenced. 

(b)  In  the  case  of  a.  patient  arthrotomised  for  com- 
minuted fracture,  and  doing  well,  which  is  exceptional, 
ankylosis  should  be  promoted  by  rigid  immobilisation, 
and  resection  performed  later.  Premature  attempts 
at  movement  in  these  cases  may  provoke  symptoms 
of  severe  sepsis .  W  hile  waiting  for  the  final  orthopaedic 
operation  the  muscles  should  be  gently  massaged  to 
keep  them  iri  good  condition. 

What  position  should  be  chosen  for  ankylosis  ? 
Classically  the  acute-angled  position  is  the  one  of  choice. 


THE  ELBOW  163 

It  permits  the  best  use  of  the  hand  in  private  life,  but 
it  is  not  the  2)osition  which  gives  the  greatest  strength 
to  the  hand.  For  manual  workers  a  position  at  an 
obtuse  angle  (100")  should  be  sought  for.  According 
to  the  teachings  of  experience,  that  is  the  most  useful 
position  for  the  workman. 

The  objection  is  made  that  the  workman  is  a  private 
individual  before  being  a  workman,  and  that  flexion 
at  an  acute  angle  is  better  in  the  case  of  the  right  arm, 
as  it  is  with  the  right  hand  that  one  eats,  dresses,  etc. 
But  as  a  matter  of  fact  the  first  business  of  anyone 
wounded  in  the  right  arm  is  to  become  left-handed, 
when  this  objection  falls  to  the  ground. 

There  is  no  fixed  rule  and  one  had  best  follow  the 
classical  rule.  But  it  is  well  to  know  of  the  argument 
so  as  not  to  worry  about  a  joint  which  unites  at  a 
slightly  obtuse  angle  ;  that  position  is  not  a  bad  one 
and  ought  to  be  left,  unless  the  other  arm  is  powerless 
or  has  been  amputated,  in  which  case  the  only  good 
position  is  at  an  acute  angle. 

Which  is  the  best  time  for  an  orthopaedic  resection 
if  the  patient's  profession  calls  for  one  ?  It  is  not  well 
to  wait  too  long  because  of  the  condition  of  the  muscles, 
or  to  interfere  too  soon  because  of  periosteal  irrita- 
tion which  must  be  left  to  settle  down  :  from  eight  to 
ten  months  seems  a  suitable  period. 

It  must  not  be  forgotten  that  in  certain  callings 
requiring  power  in  the  arm,  a  painless  firm  ankylosis 
in  good  position  should  not  be  interfered  with. 

(c)  A  limb  that  Jms  been  resected  ought  not  to  be 
put  up  in  a  splint  or  an  interrupted  plaster  casing 
and  left  to  the  tender  mercy  of  any  dresser  to  look 
after  ;  it  is  as  meritorious  for  a  surgeon  to  supervise 
the  formation  of  a  new  mobile  joint  as  to  do  a  brilliant 
resection  operation. 

In  this  kind  of  surgerj^,  the  operation  itself  is  only 
one  part  of  treatment :  it  is  criminal  to  take  no 
interest  in  the  after-treatment  because  one  has  not 


164     THE  TREATMENT  OF  FRACTURES 


oneself  performed  the  first  part   of  it.      This  after- 
treatment  ought  to  follow  the  rules  given  above. 

3.  A    Patient    insufficiently    operated    upon 
ARRIVES  ^wiTH  PROFUSE  SUPPURATION. — The  affected 
part  mus't  be  radiographed 
at  once,  and  according  to 


Fig.  42. — Fracture  of  shaft 
and  lower  epiphysis  of  the  hu- 
merus treated  at  the  front  by- 
limited  esquillectomy,  e  vac  via - 
ted  on  the  twenty-second  day 
in  a  serious  septic  condition  with 
adverse  local  symptoms.  Am- 
putation appeared  necessary. 


Fiti.  43. — The  same  patient 
as  fig.  42.  Sub-periosteal  re- 
section with  esquillectomy  by 
the  rugine  had  been  performed 
on  the  twenty-fifth  day.  The 
radiograph  shows  the  condition 
eight  days  later.  The  peri- 
osteum is  already  visible  beyond 
the  shaft. 


the  indications  furnished  by  the  presence  of  missiles 
or  splinters,  intervention  must  be  practised. 

Any  missile  must  be  removed. 

Any  suppuration  which  is  of  bony  origin  is  the 
product  of  osteitis  rather  than  arthritis.     It  must  be 


THE  ELBOW 


165 


treated  by  operation.  Multiple  incisions  doubtless 
sometimes  succeed  in  obtaining  the  desired  result, 
but  these  successive  operations  end  by  leaving  anky- 
losis with  sinuses,  after  severe  pain,  and  a  limb  which 
is  wasted,  indurated,  and  fur- 
rowed with  adhesions  and  scar 
tissue. 

It  is  best  to  perform  sub- 
periosteal resection  at  once. 


Fig.  44, — The  same  patient  as  figs. 
42,  43,  and  45.  The  same  radiograph 
showing  the  maximal  active  flexion  at 
the  end  of  five  months.  The  regular 
form  of  the  regenerated  extremities 
of  the  bones  of  the  forearm  and  the 
adaptation  of  the  newly-formed  hu- 
meral callus  are  noticeable. 


Fig.  45.— Full-face 
radiograph  five  months 
after  resection,  showing 
the  degree  of  extension 
and  the  singular  contour 
of  the  new  epiphyses. 
The  loss  of  substance  on 
the  inner  side  is  probably 
due  to  the  fact  that  the 
esquillectomy  performed 
at  the  front  was  not  done 
sub-periosteally. 


If  this  be  done  exactly  ac- 
cording to  the  rules  given 
above,  it  immediately  arrests 
infection  and  stops  suppura- 
tion ;     after    which    one    may 

obtain  a  remarkable  anatomical  and  functional  re- 
covery (see  figs.  44  and  45).  Oilier  himself  had  a 
tendency  to  i^refer  this  late  resection  to  the  earlier 


166     THE   TREATMENT  OF  FRACTUREt^ 

operation,  which  he  dreaded  on  theoretical  grounds, 
because  he  feared  an  insufficiency  of  periosteum 
which  I  have  never  met  with  after  primary  re- 
section. I  have  done  secondary  resection  eight 
times,  with  seven  good  results  and  one  passable 
one  which  is  improving.  While  preferring  primary 
resection,  the  results  of  which  are  much  more  perfect 


Fig.  4G. — Casing,  with  spring  for  mobilising  the  elbow  for  use 
with  timid  patients  or  for  those  who  have  a  flail-joint.  In  this 
latter  case  the  apparatus  will  bo  removable  to  permit  massage 
and  exercise. 

anatomically  and  physiologically,  I  consider  secondary 
resection,  early  or  late,  an  excellent  operation.  Tech- 
nically in  these  cases  it  is  well  to  be  warned  against 
a  troublesome  incident  which  may  possibly  occur  in 
resection  :  while  section  of  the  humerus  is  being  done, 
if  one  is  not  careful,  the  assistant  in  retracting  the  soft 
parts  in  front  may  reflect   too  much  of  the  inflamed 


THE   ELBOW 


167 


periosteum  and  the  denuded  shaft  of  the  bone  pro- 
jects prominently  in  the  wound.  This  accident,  which 
is  easily  avoided,  is  of  no  serious  consequence ;  all 
that  is  needed  is  to  repair  it  by  fixing  the  periosteal 
sheath  to  the  posterior  muscles  with  a  few  catgut 
sutures. 

As  to  the  post-operative  treatment,  one  of  the 
troubles  is 
combating  the 
stiffening  and 
inflammato  ry 
thickening  of 
the  muscles. 
A  very  hot 
bath,  for  half 
an  hour  daily, 
followed  b  y 
gentle  mas- 
sage, with 
attention  t  o 
m  o  v  e  m  ents, 
gives  the  best 
results  in 
these  cases. 

4.    A    Pa- 
tient IS  SEEN  WITH  A  Flail-elbow. — This  bad  result 
is  due  either  to  a  resection  with  very  extensive  loss  of 
bone,  or  to  bad  technique  in  the  operation  itself  or  its 
after-treatment. 

If  the  wound  has  not  closed,  a  piaster  casing  with  a 
spring  must  be  made  so  as  to  get  as  complete  an 
apposition  of  the  bony  extremities  as  possible,  while 
permitting  movement.  This  apparatus  is  easily  made 
by  two  circular  bandages,  one  for  the  arm  and  the 
other  for  the  forearm,  each  about  four  inches  in  depth, 
strengthened  by  two  springs  of  the  shape  shown  in 
fig.  46.  This  apparatus  should  be  left  in  position 
for  twelve  days,  and  then  taken  off  daily  for  an  hour 


Fig.  47.^ — ^The  three  radiographs  47,  48,  and 
49  show  three  stages  of  the  reconstruction  of  a 
joint  after  sub-periosteal  resection  of  a  massive 
fistvilous  ankylosis.  In  fig.  47  the  outline  of 
the  olecranon  and  the  indication  of  the  forma- 
tion of  an  epiphysis  to  the  humerus  are  notice- 
able. 


168     THE   TREATMENT  OF  FRACTURES 


or  two.  To  do  this  it  is  only  necessary  to  cut  the 
upper  bandage  down  the  back,  and  the  lower  one 
down  the  front,  when  the  apparatus  becomes  detachable. 
The  patient  takes  a  very  hot  local  bath  daily  of 
about  half  an  hour's  duration  to  make  his  muscles 
supple.  Then  after  careful  drying  he  is  massaged, 
and  if  possible  has  an  hour's  sun  bath.     At  the  end 


Fig.  48. — In  this  figure  the 
olecranon  is  hidden  behind  the 
humerus  and  is  invisible,  but  the 
formation  of  the  humeral  callus 
is  very  clearly  seen. 


Fig.  49. — Here  are  seen  the 
olecranon,  the  coronoid  process, 
and  the  trochlea.  At  this  time 
(four  months)  active  flexion 
reached  70  degrees,  active  ex- 
tension was  almo.st  normal,  and 
pronation  and  supination  were 
complete. 


of  two  or  three  months  of 

this  treatment  the  muscles 

will  have  become  supple, 

and  really  support  the  loose  new  joint,  so  that  better 

functional  use  becomes  possible. 

It  is  a  great  mistake,  then,  to  abandon  flail-elbows, 
or  to  fit  them  at  once  with  artificial  joints.     The  first 


THE   ELBOW  169 

thing  necessary  is  to  restore  the  contractile  power  of 
the  atrophied  muscles.  In  this  way  unhoped-for  success 
can  be  obtained.  By  this  treatment  I  have  restored 
useful  active  movements  to  a  patient  who  had  lost 
nearly  five  inches  of  the  humerus,  and  whose  arm  hung 
useless  at  his  side.  If  massage  fails,  before  resorting 
to  artificial  limbs  one  should  try  to  get  ankylosis  by 
refreshing  the  bony  surfaces  and  suturing  them, 
following  this  by  prolonged  immobilisation.  It  will 
still  be  possible  to  make  a  sheath  of  muscle  and 
aponeurosis  round  the  capsule  by  operation ;  recon- 
stitution  of  the  triceps  ought  thus  to  be  quite  possible. 

A  permanent  jointed  apparatus  with  a  double  armlet 
should  be  kept  as  a  last  resource  in  case  of  failure, 
or  for  patients  who  refuse  further  operation. 

5.  A  Patient  is  seen  with  Ankylosis  and  Sinuses. 
— Immediate  resection  ought  to  be  performed.  It 
should  be  done  widely,  and  the  line  of  bone  section 
should  go  high  enough  up  the  end  of  the  humerus,  and 
the  whole  of  the  sigmoid  cavity  and  the  olecranon 
should  be  sawn  off.  These  are  the  extensive  re- 
sections which  give  the  best  functional  results,  so 
long  as  the  line  of  section  runs  across  the  humeral 
epiphysis.  To  ensure  the  recovery  of  supination,  I 
am  in  the  habit  of  dividing  the  radius  with  cutting 
pliers  a  little  lower  than  the  ulna  ;  in  that  way  the 
required  mobility  is  much  more  easily  obtained. 

It  is  necessary  to  operate  in  the  same  way  for  vicious 
ankylosis  and  on  those  cases  in  which  orthopaedic 
resection  is  indicated  (see  p.  165).  After  resection, 
movement  should  be  commenced  in  ten  days  and 
pursued  according  to  the  rules  already  given. 

If  the  precepts  of  the  sub-periosteal  method  are 
followed  accurately,  remarkable  anatomical  and  func- 
tional results  will  be  obtained  (see  figs.  47,  48,  and  49). 
Up  to  the  present  time  in  wounds  of  this  kind  I  have 
had  twelve  good  results  out  of  twelve  operations  under- 
taken for  orthopaedic  reasons. 


CHAPTER    IV 
WOUNDS  AND   FRACTURES  OF  THE  WRIST 

I.  Anatomical  Types  and  Clinical  Course 

Froii  the  point  of  view  of  classification  there  are  three 
etiological,  three  anatomical,  and  two  clinical  varieties 
of  gunshot  wounds  about  the  wrist. 

Etiologically  these  are  : — 

The  bullet  wound  with  small  skin  orifices,  very  limited 
fracture  and  tunnelling  of  the  bone  without  comminu- 
tion, which  recovers  quickly  and  well  with  partial 
ankylosis  of  the  carpus. 

The  small  blind  wound  caused  by  a  shell-splinter,  a 
tiny  hole  with  contused  edges,  in  appearance  nothing, 
but  leading  rapidly  to  an  acute  arthritis  of  the 
wrist. 

More  or  less  considerable  destruction  of  the  carpus, 
the  result  of  a  bullet  fired  at  close  range  or  of  a. shell- 
splinter.  This  type  is  very  common,  especially  as  a 
large  wound  on  the  dorsum  of  the  wrist. 

Anatomically  the  injuries  may  be  purely  carpal, 
especially  in  the  two  first  groups  mentioned  above. 
They  affect  the  radius  or  ulna  fairly  seldom  and  very 
often  are  carpo-metacarpal. 

Clinically,  the  course  is  usually  mild  at  first : 
these  wounds  scarcely  ever  give  rise  to  gas  gangrene 
or  septicaemia,  because,  being  wounds  of  exposed 
parts  of  the  body,  they  hardly  ever  contain  fragments 
of   clothing,   and   because,   being   wounds    involving 

170 


THE    WRLST  HI 

skin  and  bone  only  without  extensive  damage  to 
muscles,  they  do  not  provide  the  conditions  essential 
to  the  development  of  severe  infection. 

The  danger  is  suppurative  arthritis,  the.  course  of 
which  is  sometimes  very  insidious,  but  which  demands 
rapid  action  for  its  treatment. 

Many  widely  gaping  wounds,  freely  exposed  to  the 
air,  heal  well,  but  considerable  loss  of  power  persists 
in  consequence  of  the  destruction  of  tendons,  dis- 
placements of  the  metacarpal  bones  and  fingers,  whicli 
often  necessitate  subsequent  corrective  amputations. 

n.   Primary  Therapeutic  Indications 

Because  these  injuries  have  no  immediately  severe 
symptoms,  it  does  not  follow  that  they  should  be 
neglected  :  at  the  outset  one  has  the  power  of  directing 
their  course  by  rendering  them  aseptic,  and  is  able 
to  save  the  patient  much  suffering,  and  to  reduce  to  a 
minimum  the  permanent  damage  that  must  ensue. 

Oi>eration  must  therefore  be  practised  as  early  as 
possible. 

Four  methods  of  treatment  are  open  to  discussion. 

1.  Immobilisation  pure  and  simple. — ^This  is  suit- 
able for  wounds  caused  by  long-range  bullets.  After 
painting  with  iodine  and  applying  an  aseptic  dressing, 
the  hand  is  placed  in  a  position  of  slight  dorsi-flexion 
in  a  palmar  plaster  splint,  extending  from  the  heads 
of  the  metacarpal  bones  to  a  little  above  the  elbow. 
Passing  the  thumb  through  a  hole  in  the  plaster  spUnt 
is  an  excellent  means  of  fixing  the  apparatus  and  of 
applying  it  satisfactorily  to  the  forearm.  This  splint 
is  kept  on  for  three  weeks,  when  gentle  movement  is 
commenced.  Complete  recovery  takes  place  in  one 
and  a  half  or  two  months.  Sometimes  vaso-motor 
or  nerve  troubles  persist  without  apparent  reason  ; 
they  may  be  considered  as  a  sympathetic  neuritis, 
and  treated,  as  I  have  elsewhere  indicated,  by  excision 


173     THE   TREATMENT  OF  FRACTURES 

of  the  cellular  sheath  of  the  brachial  artery,  which  is 
covered  with  nerve-plexuses. 

2.  Esquillectomy. — In  the  carpus,  where  it  is  always 
really  a  partial  resection,  this  operation  is  suited  at 
the  outset  to  all  fractures  limited  to  the  carpal  bones, 
whether  there  be  a  blind  wound  or  a  penetrating  one 
with  the  wound  of  exit  more  or  less  ragged.  It  is 
economical,  that  is  to  say  it  will  only  affect  the  bone 
(semi-lunar  or  os  magnum)  or  bones  directly  struck 
by  the  missile.  If  done  in  the  prophylactic  stage, 
there  is  no  need  to  be  afraid  of  the  many  recesses  of 
the  synovial  membrane.  When  disinfection  is  done 
early,  the  carpus  can  be  considered  as  composed  of 
one  bone  only,  and  if  the  disinfection  has  been  care- 
fully performed,  esquillectomy  is  practically  always 
sufficient  to  give  a  good  orthopaedic  result. 

It  is  the  method  of  choice  for  all  blind  wounds  of 
the  wrist  and  the  small  contused  wounds  made  by 
grenade  spUnters,  in  which  seriovis  arthritis  of  the 
wrist  sets  in  very  rapidly  if  one  does  not  intervene. 
In  these  cases  early  incision  followed  by  removal  of 
the  fractured  bone  is  a  matter  of  great  urgency  ;  unless 
partial  resection  is  performed,  total  resection  will 
have  to  be  done  in  a  short  time,  and  the  functional 
result  of  that  is  quite  another  matter.  When  the 
fracture  involves  in  addition  the  lower  articular  ends 
of  the  bones  of  the  forearm,  a  very  hmited  esquillec- 
tomy will  be  done  upon  them,  bearing  in  mind  the 
usual  mildness  of  septic  infection  in  this  region.  As 
much  as  possible  should  be  preserved,  especially  the 
styloid  processes,  w^hich  are  always  required  to  prevent 
future  lateral  displacement. 

When  the  fracture  involves  both  carpus  and  meta- 
carpus, as  Httle  should  be  done  to  the  latter  bones 
as  possible,  especially  if  the  tendons  are  intact  or 
only  sHghtly  damaged.  Fractures  of  the  metacarpus 
generally  recover  well.  The  functional  result  is  often 
better  than  one  expects.     If,  however,  there  is  much 


THE    WRIST 


173 


I 


loss  of  tendon  and  therefore  no  hope  of  satisfactory 
restoration    of    function,    less    restraint   is   necessary 
since  the  corresponding  finger  is  hopelessly  damaged. 
But  in  principle  it  is  best  to  be  extremely  conserva- 
tive in  the  case  of  both  hand  and  fingers,  since  no 

one  can  foresee  the  extent 
of  the  eventual  recovery  of 
function  of  a  deformed  hand. 
3.  Typical  Resection. — 
Naturally  this  operation  is 
only  exceptionally  called  for. 
It  should  be  reserved  for 
serious  bony  injuries,  for  de- 

FiG.  50. — A  splinter  had  entered 
the  ulnar  side  of  the  forearm,  blow- 
ing away  a  portion  of  the  ulna,  and 
had  passed  through  the  carpo- 
metacarpal area,  lacerating  the  ten- 
dons of  the  three  middle  fingers, 
and  breaking  up  the  corresponding 
metacarpal  bones.  Severe  sepsis. 
Esqviillectomy  of  the  ulna,  disarticu- 
lation of  three  fingers  and  their 
metacarpals,  and  removal  of  the  os 
magnum  have  obviated  amputation, 
which  appeared  necessary. 

struction  of  the  carpus  when 
all    the    cancellous  tissue   is 
crushed  :  in  these  cases  it  is 
performed  without  worrying 
about  accompanying  lesions 
of  the  tendons  and  muscles, 
if  the  vessels  and  the  nerves 
are  intact.     The  principle  is 
to  preserve  the  hand  some- 
how, and  besides,  when  intervention   is   done   very 
early  and  a  practically  aseptic  course  can  therefore  be 
hoped  for,  the  divided  tendons  can  be  sutured. 

4.  Total  Amputation  of  the  Hand. — ^The  only 
indication  for  disarticulation  at  the  radio-carpal  joint, 


174     THE   TREATMENT  OF  FRACTURES 

or  amputation  through  the  forea^rm.  is  complete 
crusliing  of  the  hand,  when  the  surgeon  merely  finishes 
what  the  missile  has  begun.  Whenever  it  is  possible 
to  preserve  even  a  broken  metacarpal  bone  with 
its  corresponding  finger,  an  atypical  ablation  of  the 
injured  part  is  preferable  to  total  amputation.  Every 
effort  should  be  made  when  the  thumb  is  in  question. 
Loss  of  the  hand  should  be  avoided  at  all  costs. 
For   this   purpose   limited   amputations   of   cme   or 


FK'.  31. — Disarticulation  of  the  three  middle  metacarpals  with 
partial  resection  of  the  carpus  and  free  esquillectoniy  of  the  ulna. 
The  lol)stor-claw  action  from  a  photograph  taken  six  months  after 
the  injury  :  the  jiatient  can  make  a  cigarette,  placing  the  paper  on 
a  table. 

more  fingers,  combined  with  partial  resection  of  the 
carpal  bones,  should  be  freely  used.  When,  for  example, 
an  injury  to  the  wrist  is  accompanied  by  total  destruc- 
tion of  three  metacarpals  and  their  tendons,  they 
should  be  removed  with  their  corresponding  carpal 
bones,  leaving  only  the  internal  and  external  sup- 
ports of  the  carpus.  The  lobster's  claw  thus  made 
will  be  all  the  more  mobile.  Doubtless  in  these  cases 
it  might  be  possible  at  times  to  cause  the  disappear- 


THE    WRIST  175 

ance  of  septic  phenomena  by  means  of  a  limited 
esquillectomy,  but  recovery  is  difficult  and  leaves 
fingers  ankylosed,  deformed  and  immobile,  and  calling 
for  removal  later  on.  Manifestly  the  sacrifice  of  the 
metacarpal  bones  should  not  be  lightly  made  :  it  is 
only  allowable  if  there  is  no  hope  that  their  corre- 
sponding fingers  will  ultimately  recover  their  mobility. 
It  will  be  said,  perhaps,  that  there  is  always  time 
to  intervene  later  if  there  is  occasion  to  do  so,  and 
that  it  may  then  be  possible  afterwards  to  limit  the 
operation  to  removal  of  the  fingers.  But  as  a  matter 
of  fact  the  free  drainage  provided  by  ablation  of  the 
carpus  and  metacarpus  favours  recovery  without  the 
formation  of  septic  cavities  and  without  cellulitis  of 
the  tendon  sheaths,  but  with  perfect  use  of  the  other 
fingers,  which  is  of  the  utmost  importance.  On  the 
other  hand,  whenever  one  removes  two  fingers,  it  is 
best  to  remove  their  metacarpal  bones  as  well,  to 
allow  of  a  better  approximation  of  the  remaining 
digits.  Similarly,  when  one  finger  is  removed,  it  is 
best  to  resect  the  head  of  the  metacarpal  to  diminish 
the  interdigital  space. 

These  combined  operations  are  perfectly  legitimate 
and  almost  always  enable  one  to  avoid  total  amputa- 
tior     f  the  hand. 

Finally,  the  operation  which  will  be  most  frequently 
performed,  for  the  purpose  of  early  disinfection,  is 
that  of  partial  resection,  either  limited  to  one  or 
extended  to  several  bones  of  the  carpus,  with  the 
addition,  if  need  be,  of  one  or  two  metacarpals. 

m.  Operative  Technique 

As  a  rule,  every  operation  on  the  wrist  for  war- 
wounds  is  decidedly  atypical  Whatever  be  the 
precise  technique  chosen,  two  important  rules  ought 
to  be  borne  in  mind. 

The  incisions  should  run  as  parallel  as  possible  to, 
and  to  one  side  of,  the  extensor  tendons. 


176     THE   TREATMENT  OF  FRACTURES 


The  denudation  of  the  bones  ought  to  be  done  with 
the  rugine,  with  which  the  periosteum,  the  Hgaments, 
and  the  muscular  insertions  Avill  be  separated.  It 
must  be  remembered  that  the  Hfe  of  tendons  is  pre- 
carious since  they  slough  easily  :  if  great  care  is  not 
used  in  exposing  them,  cicatricial  contraction  and 
adhesions  will  jeopardise  the  result. 

{a)  Access  to  the  Joint. — When  a  bhnd  wound, 

or  one  of  Hmited  extent, 
is  concerned,  the  bone 
should  be  reached  and 
exposed  by  excising  the 
wound  of  entry,  which 
is  practically  always 
dorsal.  If  the  sacrifice 
of  one  or  more  digits 
appears  necessary,  it  is 
best  to  commence  the 
operation  by  a  carpo- 
metacarpal disarticu- 
lation, which  freely 
exposes  the  depths  of 
the  wound. 

If  the  injuries  appear 
to  necessitate  merely 
an  extensive  resection 
of  the  wrist,  Ollier's 
two  para-tendinous  in- 
cisions— ^the  one  meta- 
carpo-radio-dorsal,  the  other  ulno-lateral — should  be 
employed  to  expose  the  carpus  whenever  the  wounds 
permit.  The  fonner  follows  the  radial  border  of  the 
extensor  indicis  :  it  extends  from  the  middle  of  the  line 
joining  the  two  styloid  processes  as  far  as  the  middle 
third  of  the  second  metacarpal  bone. 

After  the  tendon  has  been  defined,  the  incision  is 
carried  down  to  the  periosteum  and  the  dorsal  liga- 
ments,  avoiding    the   tendon   of   the   extensor  carpi 


Fig.  52. — Para-tendinous  incisions 
for  resection  of  the  wrist. 


THE    WRIST  177 

radialis  brevior,  the  insertion  of  which  is  hidden  by 
the  extensor  indicis  tendon.  The  periosteum  is 
incised  over  the  inner  edge  of  the  head  of  the  third 
metacarpal,  where  the  rugine  will  commence  to  raise 
the  capsiilo-periosteal  sheath. 

The  ulnar  incision  commences  a  little  above  the 
styloid  process  of  the  ulna  and  runs  down  to  a  point 
1  in.  above  the  lower  end  of  the  fifth  metacarpal, 
nearer  its  palmar  than  its  dorsal  aspect,  so  as  to  leave 
the  tendon  of  the  extensor  carpi  ulnaris  in  the  dorsal 
margin  of  the  wound.  This  incision,  which  crosses 
a  cutaneous  branch  of  the  ulnar  nerve,  which  should 
not  be  cut,  exposes  the  cuneiform  and  the  uncifonu 
bones.  It  is  needless  to  go  over  the  remaining  stages 
of  the  operation  :  they  comprise  division  of  the  pos- 
terior annular  hgament  to  allow  retraction  of  the 
tendons,  denudation  of  the  bone,  and  extraction  of 
fragments  by  means  of  the  rugine  :  they  are  all  easy 
enough. 

Incisions  over  the  outer  side  of  the  radius  should 
be  avoided  as  much  as  possible,  because  of  the  presence 
of  the  radial  artery. 

IV.   Post-Operative  Treatment 

1.  A  CASE  OF  Total  Resection  of  the  Carpus 
will  be  immobilised  in  a  plaster  casing  after  an  aseptic 
dressing  has  been  appUed. 

This  will  be  done  in  the  following  manner  : 
Six  double  thicknesses  of  tarlatan  are  cut  to  make 
a  splint  extending  from  the  lower  third  of  the  arm  to 
the  level  of  the  transverse  palmar  crease,  leaving  the 
fingers  free.  A  prolongation  will  shghtly  separate  the 
thumb  from  the  index  finger,  which  is  the  best  method 
of  obviating  loss  of  opposed  action  later.  The  spHnt 
only  covers  half  the  circumference  of  the  limb,  which 
is  semi-pronated,  with  the  hand  in  a  position  of  dorsi- 
fiexion.     The  hand  must  be  well  supported. 


]78     THE   TREATMENT  OF  FRACTURES 

At  each  dressing  the  spHnt  is  removed  and  the  hand 
carefully  kept  dorsi-flexed  by  an  assistant.  If  the 
plaster  has  softened,  it  must  be  renewed  :  it  is  of 
importance  that  immobiUty  should  be  perfect.     The 


Fig.  53. — Casing  for  immobilisation  of  the  wrist. 

plaster  is  kept  on  for  several  months.  The  hand  has 
a  constant  tendency  to  fall,  both  on  account  of  its 
own  weight  and  of  the  predominance  of  the  flexor  over 
the  extensor  muscles.  At  an  early  date  passive  and 
active  movements  of  the  fingers  will  be  commenced ; 
these  soon  get  stiff  if  they  are  not  moved,  and  are 


Fig.  54. 


then  very  difficult  to  restore  to  their  normal  mobilityi 
Interrupted  plaster  spHnts  ought  not  to  be  used  at  the 
wrist,  because  they  do  not  leave  the  fingers  sufficient 
liberty  of  movement.  In  fine,  one  ought  never  to 
lose  sight  of  the  double  object  to  be  attained  :  fibrous 


THE    WRIST  179 

ankylosis  of  the  wrist  in  good  position,  and  mobility 
of  the  fingers, 

2.  In  Partial  Resection  it  will  be  quite  otherwise. 
One  can  and  ought  to  restore  free  movement  to  the 
wrist  :  the  hand  has  no  tendency  to  fall  or  to  deviate 
from  its  proper  position.  At  an  early  period  exercises 
ought  to  be  commenced,  so  as  to  produce  a  supple 
carpal  joint.  If  all  local  and  constitutional  symptoms 
of  sepsis  have  disappeared,  they  will  be  undertaken 
as  early  as  the  eighth  day,  and  should  be  progressive 
and  gentle,  first  passive,  and  later  active.  There  is 
no  need  for  hurry  :  it  is  a  question  of  patience,  not 
speed. 

In  the  intervals  between  the  movements  the  limb 
is  replaced  in  the  plaster  splint,  which  will  not  be 
finally  discarded  until  after  a  fortnight  or  three 
weeks. 

3.  In  Partial  Carpo-metacarpal  Amputation  it 
will  be  well  to  employ  hypertonic  saline  solution 
as  a  dressing  for  a  week.  When  the  wound  is  not 
perfectly  aseptic,  a  little  arthritis  develops  round  the 
carpus :  this  is  shown  by  an  oedematous  swelling  of 
the  hand,  which  a  dry  dressing  does  not  easily  subdue. 
The  osmotic  currents  produced  by  the  concentrated 
saline  solution  hinder  absorption  in  the  many 
synovial  sacs  exposed  and  favour  the  cure. 

This  moist  saline  dressing  does  not  permit  the  limb 
to  be  retained  in  the  plaster  casing.  During  this 
period,  therefore,  the  hand  is  supported  in  a  position 
of  slight  dorsal  flexion  upon  a  wide  wooden  splint, 
the  hand  part  being  firmly  padded  with  sterilised 
cotton  wool.  The  sj^lint  ought  to  extend  up  as  far 
as  the  upper  third  of  the  forearm  to  make  the  patient 
comfortable. 

After  eight  to  ten  days  of  these  moist  saline  dress- 
ings, which  are  renewed  daily  or  every  second  day, 
according  to  the  temperature  chart,  the  ordiuaxy  dry 
aseptic   dressing  is  reverted   to.     At  an  early  date, 


180    THE   TREATMENT  OF  FRACTURES 

mobilisation  of  the  fingers  and  phalanges  will  be  con- 
sidered. 

V.   Evacuation  of  Patients  with  Wrist  Wounds 

No  one  wounded  in  the  wrist  should  be  evacuated 
without  primary  operation  except  he  be  a  case  of 
bullet  wound  with  punctiform  openings.  All  should 
be  operated  upon  with  the  least  possible  delay,  as  has 
been  indicated  above. 

At  the  end  of  forty-eight  hours,  if  the  operation  has 
been  sufficiently  radical  and  all  is  going  well,  a  patient 
who  has  undergone  partial  resection  can  be  sent  out 
without  risk ;  if  he  has  had  total  resection  done,  eight 
days  ought  to  be  allowed  ;  and  the  same  period,  or  a 
little  less,  if  partial  amputation  has  been  performed  and 
the  result  appears  favourable. 

The  limb  should  be  immobilised  in  a  plaster 
apparatus,  made  as  described  above,  viz.  a  palmar 
splint  extending  from  the  flexure  of  the  fingers  to 
above  the  elbow,  the  hand  being  slightly  dorsi-flexed. 
The  plaster  should  be  removed  and  reapplied  on  arrival. 
The  journe}^  should  not  exceed  twenty-four  hours. 

VI.   Treatment  of  Patients  seen  late  or  after  Evacuation 

1.  When   a   Patient,  who   has  been   operated 

UPON    EARLY,    ARRIVES    IN    GOOD    CONDITION. — He  has 

undergone  a  primary  resection,  partial  or  total,  of  the 
carpus,  and  he  ought  to  recover  rapidly  with  move- 
ment of  the  joint  (in  case  of  local  removal  of  bone), 
or  with  ankylosis,  if  the  after-treatment  is  suitably 
supervised,  as  has  been  set  out  above. 

2.  A  Patient,  who  has  not  been  operated  upon, 

OR  has   been  INSUFFICIENTLY   INCISED,  ARRIVES  WITH 

Arthritis  of  the  Wrist.— This  arthritis  practically 
always  involves  the  whole  joint.  Normally,  the  wrist- 
joint  possesses  many  distinct  and  independent  synovial 


THE   WRIST 


181 


membranes,  but  they  have  many  coiitiguous  diverti- 
cula, they  are  in  immediate  contact,  and  there  are 
often  minute  channels  of  communication  between  them . 
As  soon  as  one  of  these  is  opened  and  becomes  infected, 
the  different  articulations 
are  rapidly  attacked,  as 
if  there  were  but  one  syno- 
vial membrane  and  one 
articulation.  On  the  other 
hand,  if  a  missile  traversing 
one  of  the  bones  has  been 
stopped,  as  it  often  is,  at 
the  palmar  surface  in  con- 
tact with  the  synovial 
sheaths,  there  is  almost 
always  a  deep  abscess 
there  and  this  can  only 
be  opened  and  drained  by 
extensive  resection.  This 
is  not  the  time  for  limited 
arthrotomies  and  economi- 
cal resections.  Partial  re- 
section is  as  valuable  as 
a  primary  operation  as  it 
is  detestable  as  a  secondary 
measure.  Complete  re- 
moval of  the  carpus  should 
be  effected  at  once ;  it  is 
impossible  to  remove  a 
single  bone  without  open- 
ing the  neighbouring  serous 
membranes,  and,  if  they  are  invaded,  intervention  has 
only  served  to  spread  the  mischief. 

On  the  other  hand,  if  one  delays,  the  synovial  sheaths 
of  the  flexors  are  attacked ;  purulent  foci  are  formed 
in  the  forearm,  the  constitutional  symptoms  become 
worse,  and  the  function  of  the  hand  is  definitely  en- 
dangered.    Certain  parts  of  the  carpal  bones,  viz.  the 


Fig.  55.— Secondary  arthritis 
of  the  wrist  after  a  blind  wound 
caused  by  shell- splinter.  The 
patient,  retained  in  a  hospital 
at  the  front  for  a  wound  of  the 
skull,  was  evacuated  on  the 
twelfth  day  with  a  small  dorsal 
woiind  of  the  wrist  apparently 
doing  well.  The  radiograph 
taken  on  the  fifteenth  day 
showed  a  small  projectile  and 
a  blurred  appearance  of  all  the 
metacarpal  bones ;  the  wrist 
was  rather  swollen  and  painful, 
the  patient  slightly  febrile. 


182     THE   TREATMENT  OF  FRACTURES 


unciform  process  and  the  tubercle  of  the  scaphoid 
which  constitute  the  lateral  boundaries  of  the  palmar 
carpal  groove,  have  their  periosteum  intimately 
blended  with  the  synovial  membranes  of  the  flexor 
sheaths ;  their  infection  miist  be  prevented  at  any  cost, 
and   to    ensure   this,    total    resection    of    the    carpus 

should  be  done 
without  delay ;  be- 
sides, it  gives  ex- 
cellent results  and 
avoids  secondary 
amputations. 

But  the  situa- 
tion may  be  more 
complicated:  when 
a  splintered  carpo- 
metacarpal frac- 
ture exists  and 
has  not  been  suf- 
ficiently cleared 
out  and  there  are 
signs  of  severe 
general  infection, 
any  fresh  inter- 
ference provokes 
an  acute  attack  of 
general  arthritis  of 
an  extremely  vio- 
lent type,  accom- 
panied by  formid- 
able general  and 
local  symptoms,  which  seems  to  demand  amputation. 
There  is,  in  short,  a  dangerous  period  in  secondary 
intervention  for  injuries  of  the  wrist.  Docs  this 
mean  that  at  this  stage  it  is  a  question  of  doing 
nothing  or  of  amputating  ?  Not  at  all.  The  post- 
operative complications  are  owing  to  the  fact  that 
surgical  interference  roughly  opens  up  the  joints  in 


Fig.  5^S. — The  same  case  as  fig.  55. 
Exploration  showed  that  the  splinter  had 
passed  through  the  os  magnum  and  was 
embedded  in  the  palmar  ligaments.  The 
bones  of  the  carpus  had  all  lost  their 
cartilaginous  covering,  except  the  upper 
part  of  the  scaphoid  and  the  semi- 
lunar. There  was  a  large  palmar  abscess 
spreading  along  the  sheaths  towards  the 
forearm.  The  rather  unusual  aspect  of 
the  plate  is  due  to  the  position  of  dorsal 
flexion  in  which  the  hand  was  immo- 
bilised. Radiograph  taken  three  days 
after  operation,  which  gave  a  good  result. 


THE    WRIST  183 

the  vicinity  of  the  one  primarily  affected  and  infects 
them. 

In  order  to  prevent  operation  from  being  followed 
by  bad  symptoms,  and  in  order  to  avoid  this  acute 
arthritis,  it  is  necessary  immediately  to  expose  the 
carpus  in  the  neighbourhood  of  the  injury  and  either 
remove  it  or  the  broken  metacarpal  bones  and  the 
damaged  tendons.  By  laying  the  cavity  widely  open 
and  combining  partial  resection  of  the  carpus  with 
amputation  of  the  metacarpals  and  fingers  which  have 
been  injured,  the  sepsis  is  limited  and  a  hand,  though 
a  poor  one,  is  saved. 

To  sum  up,  these  cases  are  not  to  be  treated  by 
esquillectomy  or  by  local  operations,  but  by  combined 
amputation  and  resection,  followed  by  dressing  with 
a  hypertonic  salt  solution  and  by  satisfactory  immo- 
bilisation. 

3.  When  a  Patient  is  seen  late  with  persistent 
Suppuration.— If  there  is  an  obstinate  sinus,  limited 
resection  by  means  of  the  rugine  is  indicated. 

If  some  of  the  fingers  are  deformed  or  drawn  out  of 
position  and  useless,  appropriate  disarticulation  can 
be  done. 

Troublesome  tendinous  adhesions  are  remediable  by 
the  interposition  of  fatty  grafts  between  the  cicatrices 
and  the  tendons.  I  have  obtained  excellent  results 
by  these  means. 


CHAPTER    V 
WOUNDS  AND  FRACTURES   OF  THE  HIP 

I.   Anatomical  Types  and  Clinical  Course 

Wounds  of  the  hip-joint  appear  rare  when  we  con- 
sider the  frequency  of  joint  wounds  in  general.  This 
is  not  due  to  the  lucky  escape  of  this  deeply  seated 
joint  but  rather  to  the  extreme  gravity  of  the  wounds, 
a  great  number  of  which  are  accompanied  by  fracture 
of  the  pelvis,  injury  of  the  bladder,  and  perforation 
of  the  intestine,  and  rapid  death  is  the  usual  result. 
Besides,  bullet  wounds  with  explosive  effects  produce 
in  the  massive  muscular  covering  of  the  hip  such 
formidable  damage,  and  such  destruction  of  vessels 
and  nerves,  that  immediate  death  from  shock  and  loss 
of  blood  is  very  common.  In  this  way  many  wounds 
of  the  hip- joint  escape  observation,  and  the  number 
is  reduced  to  those  one  is  called  upon  to  treat. 

In  practice  the  following  types  must  be  dis- 
tinguished : 

(a)  A  Bullet  Wound  ivith  pmictiform  sJcm-openings. — 
The  bullet  perforates  the  neck  or  the  head  of  the  bone 
under  most  variable  circumstanes,  producing  perhaps 
a  limited  injury  (furrow,  perforation,  erosion),  or 
perhaps  bony  damage  which,  though  considerable,  may 
yet  run  an  aseptic  course.  Usually  voluminous  callus 
is  formed  and  there  is  ankylosis  of  the  hip. 

(6)  Cancellous  crushing,  ivith  a  retained  missile. — 
This  is  the  starting-point  of  progressive  osteitis : 
according  to  its  position,  in  the  neck  or  the  head  of 

184 


THE  HIP 


185 


the  bone,  articular  osteitis  is  more  or  less  early  in 
appearing.  But  as  a  general  rule,  an  acute  suppura- 
tive arthritis  is  developed,  which  may  lead  to  a  rapidly 
fatal  result  if  immediate  intervention  is  not  under- 
taken, or  to  a  less  acute  form  of  the  disease  which  leads 
to  ankylosis  after  pretty  severe  suppuration, 

(c)  Separatio7i  of   the  head  of  the  femur. — This  is  a 


St*?,?-:  •.•;.•• 
r-"  '■■^  -' 


Fig,  57. — Separation  of  the  head  of  the  femur  by  a  shell-splinter 
with  a  postero-anterior  wound.  Primary  resection  by  anterior 
incision.     Recovery, 

frequent  injury  arising  from  shell-splinters  coming 
from  a  height.  At  first  the  trouble  may  appear  slight, 
but  towards  the  third  or  fourth  day  an  acute  arthritis 
develops,  with  septicaemia  and  suppuration  of  the 
neighbouring  muscles  of  a  sloughing  type.  The.  head 
of  the  bone  forms  a  deep-seated  sequestrum,  and  if  it 
is  not  removed  without  delay  death  pretty  certainly 
supervenes. 


186    THE  TREATMENT  OF  FRACTURES 


'~}y\^     'wS''    ;•/■''.'' 


(c?)  Transverse  fracture  through  the  trochanters. — The 
projectile  entering  at  the  great  trochanter  finds  its 
way  towards  the  lesser  one,  above  or  below  it,  without, 
as  a  rule,  interrupting  the  continuity  of  the  shaft. 
But  the  violence  of  the  injury  has  an  extremely  severe 
effect  within  the  joint,  which  it  is  always  important 

to  recognise  and 
look  out  for  ;  a 
fracture  of  the 
neck  is  caused 
by  contre-coup. 
In  consequence 
of  the  infection 
produced  by  the 
passage  of  the 
missile,  there  is 
rapid  develop- 
ment of  a  gan- 
grenous articu- 
lar osteitis  of  a 
very  grave  type 
which  is  almost 
always  fatal. 

(e)  Smashing 
of  the  hip. — This 
is  seen  s  o  m  e- 
times  in  large 
wounds  of  the 
outer  side  of  the 
thigh  and  the 
buttocks  which 
do    not  involve 


Fio.  58. — Fracture  of  the  neck  by  contre- 
coup,  the  wound  passmg  through  the 
trochanter.  The  separation  of  the  head  of 
the  humerus  was  not  recognised  in  the  ab- 
sence of  radiography.  Later  resection  of 
the  head  did  not  prevent  the  death  of  the 
patient  by  sepsis.  Early  resection  would 
have  been  followed  by  recovery. 


the  femoral  ves- 
sels and  sciatic  nerve.  The  wounded,  who  are  always 
under  the  influence  of  extreme  shock,  may  survive, 
but  quite  exceptionally.  The  enormous  damaged  area 
of  which  the  joint  is  the  centre  is  ready  to  become 
infected,  and,  unless  rapid  intervention  is  undertaken, 


THE   HIP  187 

an  acute  gangrenous  septicaemia  rapidly  carries  off  the 
patient. 

Each  of  these  fractures,  whatever  the  type,  may  be 
Single,  but  more  frequently  fissures  of  the  acetabulum 
or  of  the  iliac  bone  accompany  them.  At  other 
times  they  are  associated  with  visceral  lesions,  vesical 
fistulse,  or  ruptures  of  the  colon.  These  are  grave 
complications  which  make  it  all  the  more  urgent  to 
practise  an  intervention  capable  of  enabling  the 
osteo-articular  injury  to  run  an  aseptic  course.  In  all 
these  cases  the  prognosis  should  be  very  guarded. 

n.   Primary  Therapeutic  Indications 

It  is  well  to  put  on  one  side,  as  usual,  those  cases 
of  bullet  wounds  with  very  narrow  cutaneous  openings, 
the  treatment  of  which  is  identical  with  that  of  simple 
fractures ;  that  is  to  say,  immediate  immobilisation 
in  a  plaster  casing  extending  from  the  back  of  the 
pelvis  to  below  the  knee,  or  in  a  plaster  spica  enclosing 
the  whole  lower  limb,  which  is  fixed  in  a  position  of 
extension  and  abduction.  The  extension  should  be 
kept  up  while  the  plaster  is  being  applied,  unless  it  is 
going  to  be  applied  secondarily:  The  patient  recovers 
with  ankylosis  and  often  with  marked  shortening.  It  is 
unusual  for  the  seat  of  fracture  to  be  infected  primarily, 
but  an  obstinate  sinus  is  not  an  unusual  after- develop- 
ment :  I  have  seen  several  examples  of  it.  Barring 
these  cases,  which  are  becoming  less  and  less  frequent  in 
trench-warfare,  all  other  wounds  of  the  hip  and  all 
those  caused  by  splinters  of  shell  or  grenades  ought  to  be 
operated  upon  at  once,  because  from  the  first  they  are 
all  in  imminent  danger  of  severe  infection.  Owing  to 
the  depth  of  the  joint  and  the  difficulty  of  reaching 
it,  one  is  doubtless  tempted  to  immobilise  the  limb 
and  wait  for  symptoms  of  the  onset  of  infection  before 
doinpf  anything  further.  But  this  is  a  deplorable 
course  to  take  :    at  the  hip,  the  necessity  of  operative 


188    THE  TREATMENT  OF  FRACTURES 

measures  which  are  prophylactic  against  infection  is 
as  pressing  as  anywhere  else,  if  not  more  so.  If  the 
patient  is  suffering  from  shock,  he  must  be  treated  by 
means  of  the  usual  stimulants  (oil  and  camphor,  artificial 
serum) — morphine  is  very  useful  in  severe  cases  of 
shock — and  then  early  operation  must  be  undertaken 
without  waiting  for  the  clinical  signs  of  established 
septic  poisoning. 

Three  operations  have  their  indications  and  must  be 
considered. 

1.  Limited  EsquiUectomy  and  Drainage. — Theoreti- 
cally this  operation  is  suited  to  partial  lesions,  to  some 
degree  extra-articular,  as  for  instance  certain  marginal 
fractures  of  the  great  trochanter.  But  the  frequency 
of  fracture  by  contre-coup  of  the  head  or  the  neck 
limits  the  employment  of  it  in  practice.  One  should 
never  admit  a  priori  that  a  fracture  of  the  trochanter 
is  the  only  one,  until  radioscopy  has  proved  that  it 
is  so,  and  unless  it  is  a  case  of  incomplete  cancellous 
crushing  caused  by  a  missile  which  remains  in  situ. 

Simple  esquillectomy  is  scarcely  ever  indicated  for 
injuries  which  are  properly  speaking  articular.  Indeed , 
at  the  hip  it  is  very  rare  to  see  partial  and  limited 
injuries ;  in  consequence  of  the  anatomical  con- 
formation of  the  upper  extremity  of  the  femur,  one  sees 
hardly  any  but  complete  fractures  such  as  those  of 
the  neck  and  head,  and,  for  my  own  part,  I  have  never 
met  with  any  others.  Hence  it  can  be  seen  that,  the 
joint  being  a  very  close-fitting  one,  arthrotomy  is  an 
illusory  operation,  and  it  is  only  by  wilfully  deceiving 
one's  self,  that  one  can  hope  for  anything  from  it. 

The  objection  has  been  raised  that  patients  have 
recovered  after  drainage  through  the  buttock  or  thigh  ; 
but  to  begin  with,  were  they  cases  of  articular  lesions  ? 
The  mistake  is  so  easy.  Let  us  admit  that  some 
recover,  as  anyone  can  see  for  himself.  But  these 
are  only  fortunate  exceptions  :  under  the  big  muscles 
covering  the  hip- joint,  simple  drainage  cannot  suffice 


THE  HIP  189 

to  cure  a  deep-seated  osteitis,  which  elsewhere  requires 
resection.  It  is  certain  that  the  patients  who  have 
died  or  have  suffered  from  obstinate  sinuses  are  much 
more  numerous. 

It  is  said,  too,  that  it  is  difficult  to  do  anything 
else,  and  that  simple  drainage  round  the  joint  will 
always  remain  the  method  in  general  use.  But  I 
cannot  think  that  this  is  founded  upon  precise  ana- 
tomical and  clinical  data  :  this  treatment  by  drainage 
is  not  adopted  because  of  the  good  results  it  gives, 
but  by  reason  of  timidity  in  operating,  and  of  a  general 
want  of  precision  in  diagnosis.  One  fact  dominates 
the  situation :  the  mortality  from  sepsis  is  con- 
siderable among  those  who  have  escaped  death  from 
shock  or  haemorrhage,  and  operations  for  drainage 
without  free  removal  of  bone  do  little  to  diminish 
this  secondary  mortality.  Logically  it  cannot  be 
otherwise.  There  is  no  reason  why  a  joint  so  deeply 
situated  should  not  follow  the  usual  course  of  wounds 
of  joints,  and  it  should  be  admitted  as  a  principle 
that,  except  in  very  rare  cases,  justified  by  radio- 
graphy, a  blind  esquillectomy  cannot  constitute  a 
sufficient  method  of  treatment  for  wounds  of  the  hip- 
joint. 

2.  Resection. — It  is  quite  different  with  resection, 
which,  while  it  removes  the  head  of  the  femur,  gets 
rid  of  the  principal  lesion,  and  freely  exposes  the 
seat  of  injury  :  under  these  circumstances  no  infection 
ensues,  and  the  wound  progresses  without  complica- 
tions, like  all  war-wounds  which  are  treated  logically 
and  in  time.  Resection  has  the  further  advantage 
of  permitting  direct  treatment  of  the  rim  of  the 
acetabulum,  or  the  bottom  of  its  cavity. 

The  only  objection  that  can  be  urged  against  it 
is  the  poorness  of  its  orthopaedic  results.  When,  in 
order  to  remove  the  head  which  has  been  separated 
from  the  neck,  or  to  saw  through  the  neck  in  front 
of  the  trochanters,  a  free  denudation  of  these  latter  is 


190    THE   TREATMENT  OF  FRACTURED 

carried  out,  the  insertions  of  the  muscles  into  the 
trochanter  are  more  or  less  disorganised,  the  external 
attachments  of  the  capsule  are  destroyed,  and  the 
upper  extremity  of  the  femur  is  gradually  dislocated 
upwards  and  backwards  on  to  the  ilium.  If  to  this 
is  added  the  loss  of  power  resulting  from  the  damage 
done  to  the  muscles  and  nerves  of  the  buttock  it  is 
easily  understood  that  the  result,  so  far  as  the  function 
of  the  joint  is  concerned,  leaves  much  to  be  desired. 

It  is  true  that  the  wounded  survive,  and  that  is  a 
consideration.  But  there  is  more  than  this  to  be 
said  :  the  functional  result  after  resection  can  be 
much  improved  by  making  an  anterior  incision  leading 
straight  on  to  the  neck  and  head  of  the  bone,  which 
allows  resection  of  both  with  a  minimum  of  damage. 
Under  these  circumstances,  the  orthopaedic  result  is 
excellenl,  and  resection  becomes  an  operation  at 
once  conservative,  beneficent,  and  useful.  Resection 
should  be  employed  at  once  then  for  all  fractures 
of  the  head  and  neck  caused  by  splinters  of  shell  and 
grenade,  or  by  a  bullet  fired  at  short  range. 

3.  Pisarticulation. — ^When  there  is  considerable  dam- 
age of  the  explosive  type,  when  the  fracture  involves 
both  shaft  and  epiphysis,  when  the  upper  third  of 
the  femur  is  reduced  to  fragments,  early  disarticulation, 
immediately  the  shock  has  passed  off,  or  has  suffi- 
ciently abated,  is  indicated  as  the  only  chance  of 
saving  life. 

To  sum  up,  primary  resection  by  an  anterior  incision 
applies  to  almost  all  the  fractures  of  the  head  and 
neck  which  do  not  cause  immediate  death,  and  to  all 
those  in  which  preservation  of  the  limb  ought  to  be 
attempted.  The  others  are  amenable  only  to  dis- 
articulation . 

in.   Operative  Technique 

1.  Resection. — Resection  should  be  performed  in 
as  typical  a  manner  as  possible  ;    the  orifices  of  entry 


THE  HIP 


191 


and  exit,  without  exception,  ought  only  to  be  used 
as  means  of  drainage,  not  as  means  of  access.  Clas- 
sically, the  most  direct  incision  to  the  hip  is 
the  postero-external  one ;  most  often  it  traverses 
the  whole  length  of  the  gluteus  maximus,  crosses  the 
medius  and  minimus,  and  finally,  after  opening 
the  capsule,  severs  the  tendinous  attachments  of  the 
glutei  muscles  and  those  between  the  trochanter  and 
the  pelvis.  This  method  has  the  great  advantage  of 
draining  a  t 
the  lowest 
point,  but 
the  ortho- 
paedic result 
is  only  mod- 
erate. There 
is  no  ankylo- 
sis, and  the 
femur  slides 
over  the  iliac 
bone  in  a 
position  o  f 
marked  ad- 
duction. 

The  an- 
terior inci- 
sion, which 
exposes  the 
joint  with- 
out sacrific- 


Fio.  59. — Luxation  of  the  femur  on  the  ilium 
after  resection  by  a  posterior  incision.  Compare 
this  with  the  result  shown  in  fig.  60 .  (Radiograph 
contributed  by  Berard.) 


1 n  g      any 
muscles    or 

nerves,  gives  a  very  much  better  orthopaedic  result. 
By  preserving  intact  the  insertion  of  the  gluteus 
medius  and  minimus,  the  muscles  passing  from  the 
pelvis  to  the  trochanter  and  the  most  important  part 
of  the  capsule,  it  f a vourr ankylosis  and  consequent!}^ 
ensures  a  satisfactory  result.     It  is,  moreover,  easier 


192     THE  TREATMENT  OF  FRACTURES 


to  perform  and  does  not  inflict  any  severe  operative 
damage  ;  on  this  ground  it  is  specially  indicated  as 
the  primary  operation  of  choice.  To  realise  its 
advantages  the  technique  advised  by  Berard,  and 
used  by  him  with  excellent  functional  results,  should  be 
employed. 

In  this  method  the  anterior  incision  follows  the 
long  axis  of  the  head  and  neck,  starting  from 
the  anterior  inferior  iliac  spine  to  end  a  little  below 


Fig.  go. — Resection  of  the  hip  l:)y  anterior  incision.     (Radiograph 
of  a  case  operated  upon  by  Berard.) 

the  top  oi  the  trochanter.  It  thus  opens  up  the  space 
between  the  tensor  vaginae  femoris  and  the  gluteus 
minimus  on  the  outside,  and  the  external  border  of 
the  sartorius  and  the  psoas  on  the  inside.  The  muscles 
are  well  retracted,  the  thigh  is  semi-flexed  and  slightly 
abducted,  and  the  capsule  incised  along  its  whole 
length.  Each  edge  of  the  incision  in  the  latter  is 
held  by  forceps  and  divided  transversely  at  the  level 
of  the  brim  of  the  acetabulum,  and  this  releases  the 


THE  HIP  193 

circumference  of  the  head.  It  is  then  easy  to  remove 
the  fractured  parts.  Then  posterior  drainage  is 
established  by  the  aid  of  a  pair  of  forceps  introduced 
into  the  wound  and  made  to  protrude  in  the  buttock, 
where  they  seize  a  drainage  tube.  The  edges  of  the 
wound  of  entry  are  then  trimmed  with  as  much  care 
as  if  resection  had  not  been  done ;  the  sloughing 
muscular  tissue  is  excised,  the  missile  is  removed, 
and,  if  necessary,  the  trochanter  is  carefully  curetted. 
Then  the  operation  wound  is  closed.  The  idea  domin- 
ating all  this  detail  is  to  put  the  wounds  caused  by  the 
operation  and  the  injury  into  such  a  condition  that 
they  may  run  an  aseptic  course. 

2.  Disarticulation. — The  patients  whose  wounds 
call  for  this  form  of  treatment  always  arrive  in  a 
state  of  extreme  shock.  The  indication  is  that  inter- 
vention should  only  be  undertaken  after  an  interval 
for  rest  and  recovery.  The  operation  should  be  the 
simplest  and  least  violent ;  that  is  to  say,  one  should 
commence  by  amputating  the  thigh,  straight  through 
its  upper  third  after  ligaturing  the  femoral  vessels 
at  the  level  of  the  section ;  then  a  free  incision 
is  made  from  a  little  above  the  trochanter  down  to 
the  circular  incision.  This  gives  two  large  muscular 
flaps  out  of  which  the  injured  femur  can  be  easily 
and  rapidly  removed. 

This  cavity  is  left  wide  open  without  sutures,  and 
dressings  are  applied  flat  to  its  surface.  Immediate 
intra-venous  injection  of  artificial  serum  in  large  doses 
(1  to  1|  litres)  will  complete  an  operation,  which,  if 
performed  without  delay,  will  save  the  lives  of  some 
who  would  die  if  rapid  action  were  not  taken. 

IV.  Post-Operative  Treatment 

We  shall  only  deal  with  the  treatment  after  resection. 

(a)  Dressing    and    l7mnohilisation. — The    wound    is 

packed  with  aseptic  gauze  and  a  large  spica  bandage 


194     THE   TREATMENT  OF  FRACTURES 

applied,  with  wool  over  the  posterior  part,  in  order 
to  do  this  dressing  without  disturbing  the  resected 
joint  and  while  keeping  the  limb  in  good  position, 
three  supports  should  be  placed  beneath  the  patient, 
one  under  the  head,  another  in  the  middle  of  the 
back,  and  the  third  under  the  buttocks.  Another 
apparatus,  resembling  what  Oilier  describes  as  his 
"  pelvi-cervico  support,"  may  be  preferred.  For  this 
three  simple  padded  rests  are  used :  the  cervical 
support  is  hollowed  out  and  is  a  little  higher  than  the 
others.  They  are  all  three  arranged  on  a  board,  the 
two  upper  ones  being  moveable  and  the  lower  one 


Fig.  61. — OUier's  improvised  pelvi-cervical  support. 

being  made  fast.  To  this  latter  a  solid  vertical  metal 
rod  is  fixed  which  lies  between  the  patient's  legs  so 
as  to  prevent  the  body  from  being  pulled  down  when 
traction  is  made  upon  the  limb. 

The  patient  is  placed  upon  the  support,  and  the 
lower  limbs  are  held  in  a  position  of  abduction  by 
an  assistant.  The  hip  is  immobilised  by  means  of  a 
T-shaped  plaster  splint,  the  horizontal  limbs  of  which 
surround  two-thirds  of  the  circumference  of  the  pelvis, 
and  the  vertical,  longer  portion  is  moulded  to  the 
anterior  surface  of  the  limb.  Those  who  are  not 
accustomed  to  this  plaster  casing  will  very  likely  not 
look  kindly  upon  it  at  first  sight.  It  will  appear 
paradoxical.  Yet  in  reality  it  immobilises  very  well. 
The   patients   like   it,    and   the   dressings   are   much 


THE   HIP 


195 


facilitated.  It  is  very  strong,  and  will  serve  for  a  long 
time ;  and,  finally,  it  offers  the  advantage  of  facilitating 
the  application  of  continuous  extension. 

This  plaster  apparatus  is  made  of  eight  double  thick- 


^ 


g    ^o/igueur  Mile  du  memire  inferieur ';$ 


■^ 


ee/ttncrur' 


Fig,  62. — T-diaped  splint  for  dorsal  pelvi-pedial  casing. 

nesses  of  tarlatan  in  this  way  :  It  is  T-shaped  with 
unequal  horizontal  branches.  The  long  vertical  branch 
will  be  half  the  circumference  of  the  limb  in  width,  and 
is  cut  out  at  the  lower  end  into  a  U-shape,  the  two  sides 


Fig.  63. — Dorsal  pelvi-pedial  casing  for  resection  of  the  hip-joint. 
A  bandage  fixes  the  casing  firmly  to  the  lower  limb  and  completely 
immobilises  the  hip.     Continuous  extension  is  possible.  • 

of  which  are  intended  to  go  round  the  foot.  The  wide 
horizontal  branch  will  be  a  little  deeper  than  the 
height  of  the  pelvis  and  will  be  long  enough  to  go 
round  two-thirds  of  the  pelvic  circumference. 


196    THE  TREATMENT  OF  FRACTURES 

Before  putting  on  the  plaster,  some  wool  should 
be  placed  over  the  epigastrium,  so  as  not  to  compress 
the  abdomen,  and  a  gauze  bandage  is  applied  to  the 
limb  as  far  as  the  foot.  The  apparatus  may  be  made 
in  two  pieces,  the  pelvic  portion  widely  covering  and 
holding  in  position  the  crural  portion,  or,  better  still, 
the  two  parts  may  be  sewn  together.  The  bandage 
is  impregnated  with  plaster  and  is  moulded  to  the 
limb  by  a  few  turns  of  an  ordinary  bandage,  and  care 
is  taken  to  keep  the  limb  in  the  desired  position  during 
the  eight  or  ten  minutes  that  it  takes  to  dry.  The 
patient  is  put  afterwards  on  a  bed,  the  mattress  of 
which  rests  on  fracture  boards.  Thanks  to  this 
precaution  and  the  use  of  an  air  pillow  under  the 
buttocks,  Bonnet's  splint  can  be  dispensed  with. 

(b)  Later  Dressings. — It  is  often  necessary  to  renew 
the  dressing  the  day  after  the  operation,  or  in  the 
following  forty-eight  hours.  Anaesthesia  by  chloride 
of  ethyl  will  facilitate  matters  greatly.  The  plaster 
is  reapplied  without  difficulty.  The  plugging  in  the 
anterior  wound  need  only  be  changed  at  the  end  of 
five  or  six  days,  even  later  if  possible.  The  posterior 
drainage  tube,  if  all  goes  well,  should  be  replaced  by 
a  smaller  one  at  the  end  of  twelve  days.  If  the 
temperature  rises,  attempts  should  be  made,  under 
anaesthesia  if  necessary,  to  see  if  there  are  any  pockets 
of  pus  posteriorly,  or  retention  of  discharges  within 
the  acetabulum. 

If  the  temperature  is  raised  and  drainage  appears 
to  be  unsatisfactory,  continuous  extension  is  indicated. 
For  that  purpose,  before  replacing  the  plaster,  strips 
of  adhesive  strapping  are  applied  to  the  thigh  in  the 
form  of  a  stirrup,  according  to  Tillaux's  classical 
extension  method.  The  plaster  is  then  fitted  over 
the  limb  and  traction  applied  in  the  ordinary  way. 
If  the  wound  progresses  aseptically,  few  dressings 
are  needed.  A  cure  will  be  obtained  in  about  two 
months.    It  is  beneficial  to  maintain  immobilisation 


THE  HIP  197 

in  the  abducted  position  for  three  months  at  least; 
walking  will  only  be  permitted  when  the  patient 
wears  a  plaster  splint  surrounding  the  lower  limb.  At 
the  end  of  six  months  the  patient  may  walk  with  a 
raised  boot  and  a  stick. 


V.  Evacuation  of  Patients  with  Hip  Wounds 

Patients  wounded  in  the  hip-joint  cannot  be  moved 
at  first.  Those  injured  by  a  long-range  bullet  ought 
to  be  kept  under  observation  for  a  week.  At  the  end 
of  that  time  they  can  be  evacuated  in  a  plaster  sphnt 
embracing  the  lower  limb  and  the  pelvis,  the  wounded 
thigh  being  abducted  to  25°,  and  the  plaster  spica 
being  put  on  under  traction  (16  to  21  lb.).  The 
"  pelvi-pedial  "  splint,  described  above,  can  also  be 
used.  All  other  cases  of  wounds  of  the  hip  are  only 
to  be  evacuated  after  a  primary  prophylactic  opera- 
tion. They  should  be  kept  as  long  as  possible  in  the 
front  ambulances,  evacuated  only  l)y  short  stages, 
and  after  a  sojourn  of  at  least  fifteen  days  on  the  spot. 
The  ideal  method  is  to  keep  them  till  they  are  quite 
well. 

The  sphnt  for  transport  which  is  best  for  them  is 
the  "  pelvi-pedial "  sphnt  described  above.  If  it  is 
available,  the  patient  is  put  into  a  Bonnet's  splint, 
which  will  make  the  journey  easier.  But  this  journey 
ought  to  be  as  short  as  possible,  and  the  patient  should 
be  set  down  at  the  first  surgic?  1  s' ition  (rdai). 


VI.  Treatment  of  Patients  seen  late  or  after  Evacuation 
1.  A  Wounded  man,  picked  up  some  time  after 

BEING  INJURED,   ARRIVES  AT  THE   AMBULANCE   AT  THE 

END  OF  24  OR  48  HOURS. —Such  cases  are  frequent ; 
wounds  of  the  hip  are  profoundly  shocked,  are  gener- 
ally incapable  of  being  moved  early,  and  their  trans- 


198    THE  TREATMENT  OF  FRACTURES 

port  is  always  difficult,  especially  in  the  narrow,  wind- 
ing trenches.  Under  these  conditions  the  articular 
wound  is  practically  always  infected,  and  resection 
of  the  hip  must  be  performed  at  once. 

The  treatment  is  commenced  by  cleaning  up  the 
wounds  of  entrance  and  exit  so  that  any  foreign  bodies 
can  be  removed,  and  an  exact  idea  gained  of  the 
extent  of  the  injuries.  One  would  not  be  content  to 
diagnose  a  simple  fracture  of  the  trochanter  if  the 
wound  ran  along  the  inter-trochanteric  line.  It  would 
always  be  necessary  to  remember  the  possibility  of  there 
being  separation  of  the  head  of  the  bone  by  contre- 
coup,  and  if  radiography  is  not  available,  one  would 
try  to  ascertain  the  exact  condition  by  clinical 
examination  and  surgical  exploration. 

I  lost  a  patient  last  year  through  not  having  done 
this  :  secondary  resection  was  too  late  to  arrest 
sepsis.  On  the  other  hand,  I  cured  by  resection  a  man 
wounded  in  the  buttock,  the  head  of  whose  femur  had 
been  separated  by  a  bullet  which  had  passed  through 
the  trochanter. 

After  the  wounds  have  been  explored  and  cleared 
out,  the  anterior  incision  should  be  made,  and  resec- 
tion performed  according  to  the  technique  indicated 
above.  If  the  neck  be  found  incompletely  fractured,  it 
is  not  necessary  to  confine  oneself  to  esquiUectomy,  but 
typical  intra-cervical,  pre-trochanteric  resection  should 
be  done. 

Immobilisation  should  be  effected  by  means  of  the 
plaster  casing  already  described  and  evacuation  delayed 
as  long  as  possible. 

2.  A  Wounded  man  arrives  at   the  Base,  un- 

OPERATED     UPON,     BUT     DOING    WELL. — ^This    is    quite 

an  exceptional  occurrence.  The  missile,  which  is  not 
markedly  septic,  usually  remains  in  contact  with  the 
head  of  the  bone,  -vhich  may  or  may  not  be  fractured. 
Early  intervention  is  not  called  for,  although  the 
removal  of  a  foreign  body  is  always  necessary  ;    the 


THE   HIP 


199 


treatment  should  be  commenced  by  strict  immobilisa- 
tion for  some  days.  If  all  goes  well,  the  projectile 
should  be  removed  at  leisure  under  radioscopy  or  after 
precise  localisation.  Under  these  circumstances  opera- 
tions on  the  bone  can  sometimes  be  avoided,  leaving 
ankylosis  to  ensue  naturally.  If  there  is  any  fever, 
intervention  should  be  undertaken  without  delay  and 
according  to   the  ascertained  nature  of  the  injury. 


Fig.  04.— Bullet- wound  passing  through  the  hip  to  the  buttock 
in  August  1914,  a  sinus  remaining  ever  since.  The  hip  is  ankylosed. 
Exploration  by  the  wound  led  to  a  centre  of  osteitis  behind  the 
trochanter,  the  sinus  terminating  in  the  mass  of  the  adductor 
muscles  3  inches  from  the  crural  fold. 


It  should  be  limited  to  simpb  drainage  after  removal 
of  the  missile,  or  resection  ;  the  latter  is  often  prefer- 
able. 

3.  A  Wounded  man,  unoperated  upon,  has  a 
SUPPURATIVE  Arthritis. — Even  if  there  are  accom- 
panying visceral  injuries  (vesical  or  faecal  fistula), 
resection  of  the  hip  should  be  performed  at  once  by 


200    THE  TREATMENT  OF  FRACTURES 

the  anterior  method,  the  joint  lesions  being  much 
more  important  than  the  visceral  wound  from  the 
point  of  view  of  life.  In  these  cases  one  will  generally 
find  it  advisable  to  apply  continuous  extension  directly 
after  the  operation  ;  it  greatly  facilitates  drainage  of 
the  joint. 

4.  A  Wounded  man  is  seen  after  some  delay 

WITH   A   FAULTY    ANKYLOSIS    OR    SiNUSES. — (a)    When 

there  are  one  or  more  sinuses  at  the  hip. — After  radio- 
scopic  examination,  either  a  simple  curettage  or 
resection  will  be  performed,  according  to  the  injury 
present.  There  is  some  advantage  in  a  partial  opera- 
tion like  curettage,  in  not  following  the  fistula  but 
going  directly  for  the  bony  focus  which  keeps  it  up. 
The  sinuses  are  often  very  long,  and  to  follow  them 
accurately  considerable  damage  must  be  done. 
Instead  of  this,  it  will  be  better  to  make  directly  for 
the  point  indicated  by  the  radiograph,  or  by  explora- 
tion with  the  probe.  In  a  case  of  this  kind,  where  a 
sinus  four  and  a  half  inches  long  existed  on  the  internal 
surface  of  the  thigh  in  the  middle  of  the  adductor 
muscles,  I  was  able,  by  making  an  incision  near  the 
trochanter,  to  come  straight  upon  a  centre  of  osteitis 
in  the  neck  of  the  femur. 

(6)  When  the  limb  is  ankylosed  in  a  had  position, 
i.e.  flexion  and  adduction,  sub-trochanteric  osteotomy 
should  be  performed  at  a  distance  from  the  seat  of  the 
old  injury,  but  not  resection. 


CHAPTER    VI 
WOUNDS    AND    FRACTURES    OF    THE   KNEE 

I.   Anatomical  Types  and  Clinical  Course 

Penetrating  wounds  of  the  knee  are  articular  lesions 
which  during  the  present  war  have  given  surgeons 
the  greatest  anxiety  and  have  caused  them  the 
greatest  disappointment.  The  surprising  rapidity  with 
which  sepsis,  often  fatal,  develops,  and  the  impossi- 
bility of  checking  it  by  repeated  operations,  each  being 
too  late,  have  produced  in  the  mind  of  the  surgeons 
at  the  front  a  profound  pessimism  ;  many  have  arrived 
at  the  conclusion  that  amputation  should  be  performed 
at  the  first  appearance  of  infection,  without  waiting 
for  arthrotomy  or  resection — an  opinion  which  is  in 
marked  contrast  with  the  optimism  of  certain  surgeons 
at  the  base. 

Strictly  speaking,  this  pessimism  is  not  justified ; 
conservative  surgery  is  perfectly  suited  to  the  knee- 
joint,  but  there  is  no  part  of  the  body  where  it  is  more 
important  to  choose  straight  away  the  right  operation 
suited  to  any  given  case.  Each  operation  has  very 
precise  indications  ;  it  is  of  great  importance  to  do 
only  the  operation  required  and  to  do  it  early.  These 
indications  are  based  upon  an  exact  knowledge  of  the 
several  anatomical  types  of  injury,  which  are  as  follows  : 

(a)  A  Punctured  Wound  with  punctiform  skin- 
openings. — ^This  is  really  a  puncture  of  the  synovial 
membrane,  accompanied  or  not  by  a  fracture,  generally 
not  comminuted,  but  always  followed  by  haemarthrosis. 

201 


202    THE   TREATMENT  OF  FMACTUBES 

In  spite  of  the  local  pyrexia  of  the  first  few  days  and 
the  increase  in  the  size  of  the  knee,  these  wounds  heal 
readily  if  the  limb  is  rigidly  immobihsed,  and  the  knee 
regains  almost  normal  action  after  two  or  three 
months,  except  in  the  case  of  severe  fractures,  which 
lead  to  ankylosis,  or  at  least  to  a  considerable  hmita- 
tion  of  movement.  Out  of  38  cases  that  I  have 
collected  (10  my  own,  19  of  Gayet,  2  of  Delore,  7  of 
Cotte),  I  have  counted  38  recoveries. 

(6)  Small  or  moderate-sized  Wounds  with 
PARIETAL  Fracture  of  the  Knee  and  the  mis- 
sile IN  situ. — ^These  are  the  most  frequent  cases. 
The  wound  is  very  small  in  appearance ;  its  edges  are 
lacerated  and  contused;  pressure  sometimes  causes 
the  exudation  of  viscid  blood-stained  fluid  with  small 
blapkish  clots.  On  arrival  at  the  ambulance  the  injury 
may  appear  trifling.  An  ordinary  haemarthrosis  may 
be  diagnosed,  and  the  existence  of  penetration  of  the 
joint  only  suspected  from  the  distension  of  the  synovial 
membrane,  which  is  not  a  diagnostic  sign,  and  has  no 
absolute  importance,  because  foreign  bodies  in  contact 
with  it,  but  outside  the  joint,  often  give  rise  to  a  volu- 
minous haemarthrosis.*  If  one  rests  satisfied  with  that 
opinion,  on  the  second  day  symptoms  of  sepsis  appear 
and  generally  develop  rapidly,  until  death  occurs  after 
a  short  interval. 

This  dangerous  condition  is  due  :  (1)  to  the  presence 
in  the  joint  of  septic  particles  of  clothing,  earth, 
chalk,  etc.,  causing  acute  arthritis;  (2)  to  the  exist- 
ence of  fissures  more  or  less  prolonged  into  the  shafts 
of  the  femur  or  tibia,  whence  arises  a  formidable  osteo- 
myelitis. Unless  there  is  intervention,  death  ensues  in 
two-thirds  of  the  cases  from  gas  gangrene,  or  some- 

*  These  are  the  cases  that  lead  certain  surgeons  to  beheve  that 
a  number  of  wounds  of  the  knee  caused  by  shell-fragments  can  be 
cured  by  immobilisation,  aspiration,  or  the  application  of  ice. 
These  non-penetrating  wounds  of  the  knee  are  like  non-penetrating 
wounds  of  the  abdomen,  and  they  should  not  be  taken  into  account 
in  speaking  of  the  real  gravity  of  wounds  of  joints. 


THE   KNEE  203 

times  from  articular  septicaBmia.  Generally  the  symp- 
toms of  sepsis  force  us  to  act,  and  the  following  is  the 
course  of  events  :  After  two  days  of  immobiUsation  in 
a  splint,  the  patient  being  feverish  and  in  a  poor 
general  condition,  arthrotomy  is  performed  to  drain 
the  joint.  The  septic  condition  continues,  and  two 
days  later  fresh  drainage  tubes  are  inserted  alongside 
those  already  inserted.  Sometimes  an  incision  is  made 
in  the  popliteal  space  to  obtain  better  drainage,  but 
that  does  not  stop  the  infection  ;  the  face  becomes 
livid,  the  patient  looks  ill,  and  the  general  condition 
is  profoundly  affected.  A  resection  is  then  performed, 
while  the  temperature  is  still  high,  but  it  is  followed  by 
no  remission  of  the  symptoms  :  pockets  of  pus  form  at 
the  back  of  the  thigh  and  leg  and  phlebitis  may  occur. 
Amputation  is  finally  decided  upon,  but  it  is  too  late, 
and  the  patient  dies  soon  after.  The  whole  course  of 
the  case  has  occupied  a  fortnight  or  three  weeks. 
Here  is  a  typical  example  that  I  came  across  in  a 
patient  treated  at  the  front  and  arriving  in  my  wards 
in  a  pretty  bad  state. 

C.  J.  was  wounded  on  April  8th  by  a  shell-sphnter 
in  the  right  leg  and  knee  and  the  left  leg.  On  the 
right  side  there  was  a  fracture  of  the  tibia.  Inter- 
vention was  not  considered  necessary,  the  patient  being 
in  a  state  of  shock,  and  the  two  lower  Hmbs  were 
immobilised  and  antiseptic  dressings  apphed.  Four 
days  later,  on  account  of  severe  symptoms  of  infection, 
the  fracture  of  the  right  leg  was  explored  ;  fragments 
were  removed,  a  solution  of  iodoform  in  ether  was 
injected  into  the  wound,  and  the  knee  explored.  The 
wound  did  not  appear  to  communicate  with  the  joint  ; 
the  hsemarthrosis  was  relieved  by  puncture  and  the 
limb  immobilised  in  a  plaster  casing.  In  the  left  leg 
there  was  an  infected  fracture  of  the  fibula  and  some 
sloughing  muscular  tissue,  to  which  the  general  symp- 
toms were  attributed  ;  the  Umb  was  amputated  at 
the  seat  of   election.      In  spite  of    this  the   general 


204    THE   TREATMENT  OF  FRACTURES 

condition  remained  grave,  the  temperature  reached 
39-6°  C.  (103°  F.),  and,  on  the  17th,  arthrotomy  of  the 
right  knee  was  performed  and  a  quantity  of  pus  let  out. 
On  the  21st,  the  temperature  being  40°  C.  (104°  F.)  and 
the  pulse  130,  the  right  thigh  was  amputated.  On  ex- 
amination of  the  limb  (as  the  medical  case  sheet  which 
accompanies  the  patient  says),  a  purulent  arthritis  is 
found  with  wads  of  clothing,  a  wound  of  the  external 
condyle,  and  a  fissure  of  the  tibia  extending  right 
through  the  head.  Then  the  patient  was  evacuated 
to  the  base  three  weeks  after  his  injuries,  his  general 
condition  being  fair  :  it  is  certain  that  earlj^  interven- 
tion would  have  avoided  the  double  amputation. 
.  At  other  times,  in  an  apparently  favourable  case, 
death  occurs  from  chronic  septicaemia,  taking  about 
two  months  ;  at  the  autopsy,  abscesses  are  found  at 
the  back  of  the  leg  and  thigh  communicating  with 
the  joint,  and  there  are  miUary  abscesses  in  the 
lungs,  kidneys,  Hver,  and  spleen.  At  the  outbreak  of 
the  war  these  cases  were  so  frequent  that  for  many 
surgeons  there  was  only  one  treatment  for  injuries  of 
the  knee — amputation  of  the  thigh  at  the  first  sign  of 
sepsis. 

It  was  on  this  account  that,  in  June  1915,  Tuffier 
wrote  that  he  was  appalled  at  the  number  of  amputa- 
tions of  the  thigh  consequent  upon  injuries  of  the 
knee.  From  what  I  have  seen  at  medical  boards,  two- 
thirds,  if  not  more,  of  the  amputations  in  the  thigh 
have  been  done  for  wounds  of  the  knee.  Must  it  be 
said,  then,  that  these  wounds  are  beyond  the  resources 
of  surgery  ?  Most  certainly  not !  Wounds  of  the  knee 
only  take  this  lamentable  course  if  the  decision  to 
operate  is  not  taken  promptly  ;  the  majority  of  those 
that  are  suitably  operated  upon  in  time,  run  a  per- 
fectly simple  course  ;  but  to  operate  successfully  it  is 
necessary  to  recognise  that,  independently  of  the 
muscular  and  synovial  injury,  there  are  often  super- 
ficial cracks,  crush-fractures  or  fissures  in  the  bones, 


THE   KNEE  205 

and  that  a  missile  and  the  fragments  of  clothing  in 
contact  with  it  may  cause  these  fractures  to  become 
gravely  complicated.  However  mild  the  appearance 
may  be  at  the  outset,  if  a  missile  has  penetrated  the 
joint,  there  is  every  reason  for  the  gravest  appre- 
hension. 

(c)  Fractures  of  the  Femur,  Tibia,  or  Patella. — 
In  these  cases  the  projectile,  shell-  or  bomb-spUnter, 
penetrates  a  condyle  without  fissuring  the  bone  (a 
frequent  type),  crushes  the  cancellous  tissue  of  the 
tibia,  or  smashes  the  patella.  Sometimes,  but  less 
often,  a  double  fracture  of  the  femur  and  tibia,  or  a 
T-shaped  fracture  of  the  femur,  is  found.  In  other 
cases  a  short-range  bullet  has  smashed  the  whole  or 
part  of  the  articular  ends.  There  are  rarely  many 
bony  fragments,  at  least  in  my  experience,  while 
fissures  radiating  down  the  shaft  are  frequently 
found. 

The  occurrence  of  acute  septic  infection  is  more 
constant  and  more  formidable  in  these  cases  than 
in  the  preceding  ones.  If  the  patient  is  not  carried 
off  by  acute  septicaemia,  he  is  Hable  to  suppurative 
a;rthritis,  to  deep,  diffuse  cellulitis  of  the  thigh,  and 
to  secondary  haemorrhage  from  the  popUteal.  In 
short,  if  intervention  is  not  practised  at  once,  amputa- 
tion soon  becomes  necessary,  and  only  too  often  it  is 
unable  to  save  the  patient's  life. 

(d)  Destruction  of  the  Knee. — In  a  number  of 
cases,  not  only  are  the  articular  extremities  completely 
crushed,  but  there  is  also  considerable  damage  to  the 
shaft  of  the  bone,  and  fissures  extend  far  down  the 
length  of  the  femur  or  the  tibia.,  In  these  cases 
the  vessels  and  nerves  are  usually  damaged  ;  infection 
occurs  early  in  the  necrosed  tissues,  and  in  the  course 
of  the  first  twenty-four  hours  gangrene  develops  with 
the  formation  of  gas  and  foetid  sloughs,  if  not  true 
gas  gangrene.  There  is  immediate  and  considerable 
shock,  which  does  not  pass  off  ;  the  mucous  membranes 


206    THE   TREATMENT  OF  FRACTURES 

are  pale,  the  pulse  becomes  thready,  the  breathing 
superficial,  and  the  skin  cold  and  clammy. 

In  short,  apart  from  the  first  type  of  injuries, 
wounds  of  the  knee  are  of  extreme  gravity  if  they  are 
left  untreated  in  the  first  few  hours.  If  one  waits  for 
the  indications  of  sepsis  before  coming  to  a  decision, 
one  is  always  a  day  or  an  operation  behind -hand.  It 
is  necessary  to  act  at  once,  and  to  be  beforehand  with 
whatever  may  be  happening. 

n.   Primary  Therapeutic  Indications 

There  are  four  methods  of  treatment,  each  with 
its  own  indications  : 

1.  Immobilisation,  with  or  without  Aspiration. — 
Rigid  immobiUsation  of  the  knee,  with  aspiration  if 
there  is  abundant  hsemarthrosis,  is  suitable  for  bullet 
wounds  with  punctiform  openings,  but  for  these  only. 
Doubtless  cases  of  shell-splinter  wounds  could  be  cited 
in  which  this  simple  treatinent  has  been  sufficient  to 
obtain  a  cure,  but  these  are,  and  can  only  be,  excep- 
tions. Besides,  among  the  cases  reported  are  some 
which  are  really  only  parietal,  non-penetrating 
wounds  ;  and  in  many  others  secondary  removal  of 
the  missile  has  become  ultimately  necessary.  Simple 
immobiUsation  then  should  be  reserved  for  long-range 
bullet-wounds. 

After  careful  examination,  if  it  is  a  case  of  bullet- 
wound,  and  if  the  skin  wounds  are  both  very  incon- 
siderable, an  aseptic  dressing  should  be  appHed  with 
pressure,  without  operation,  and  a  posterior  plaster 
spUnt  applied  from  the  middle  of  the  thigh  to  the  end 
of  the  foot.  If  the  ^.^usion  i*  abundant  and  painful, 
the  synovial  membrane  may  be  punctured  if  time 
can  be  spared,  for  it  is  not  absolutely  necessary  ;  in 
any  case,  it  should  be  a  simple  aspiration.  It  is  needless 
to  inject  ether  or  any  other  antiseptic  into  the  joint, 
and  as  a  rule  there  is  no  occasion  to  repeat  the  puncture. 


THE   KNEE  207 

Rest  will  suffice  to  bring  about  a  cure. 

2.  Arthrotomy. — There  are  all  sorts  of  methods  of 
arthrotomy  of  the  knee. 

The  classical  operation  is  done  by  two  incisions  near 
the  patella,  which  are  often  made  too  small,  through 
which  one  or  two  drainage  tubes  are  passed  crosswise, 
above,  below,  or  behind  the  patella. 

Oilier'' s  arthrotomy,  which  is  Httle  known  outside  the 
Lyons  school,  comprises  four  and  sometimes  even  five 
incisions,  two  antero-lateral,  each  about  four  inches 
long,  one  on  each  side  of  the  patella,  extending  high  and 
low  enough  to  drain  the  anterior  cul-de-sac  above 
and  below  the  patella  ;  and  two  postero-lateral  in- 
cisions, 1  \  in.  long,  passing,  one  in  front  of  the  tendon 
of  the  biceps,  and  the  other  between  the  inner  ham- 
strings. The  attachments  of  the  lateral  ligaments 
are  divided  to  the  requisite  degree,  and  then  between 
the  two  incisions  on  the  same  side  a  drainage  tube  is 
passed  into  the  joint  and  under  the  synovial  membrane, 
but  not  between  the  bones.  If  necessary,  a  fifth, 
posterior,  incision  is  made  in  the  popliteal  space 
between  the  condyles. 

Jaboulay's  arthrotorny  is  a  simple  incision  of  the 
supra-patellar  pouch  :  the  foot  is  raised  considerably, 
so  that  drainage  of  the  synovial  cavity  is  made  from 
its  lowest  point. 

Anterior  transverse  arthrotomy. — This  was  described 
by  Oilier  but  little  employed  before  the  present  war. 
In  it  the  knee  is  widely  opened  by  means  of  a  curved 
incision,  convex  downwards,  cutting  through  the  liga- 
mentum  patellae.  It  was  recommended  by  Quenu 
at  the  beginning  of  the  war,  and  gives  free  access  to 
the  joint.  This  operation  has  sometimes  to  be  sup- 
plemented by  excision  of  the  patella. 

Which  method  should  be  chosen  ? 

It  is  impossible  to  answer  this  question  in  a  few 
words,  for  these  cases  are  complex ;  but  the  point  to 
insist  on  is  that  all  these  methods  are  of  little  use  if 


208     THE   TREATMENT  OF  FRACTURES 

arthrotomy  is  regarded  as  simply  an  operation  for 
drainage.  In  war-wounds  arthrotomy  should  be 
regarded  as  essentially  an  exploratory  incision,  the 
first  stage  in  an  operation  of  discovery  and  trimming 
up,  and  not,  as  it  has  often  been  called,  an  operation  for 
drainage.  When  once  the  foreign  bodies  have  been 
removed  and  the  joint  has  been  cleared  out,  the 
simplest  drainage  incision  is  the  best ;  if,  on  the  con- 
trary, foreign  bodies  are  left  behind,  the  most  elaborate 
arthrotomy  is  only  too  often  inefficient. 

Missiles  left  in  the  knee  after  arthrotomy  for 
drainage  have  undoubtedly  in  some  cases  been  well 
tolerated,  but  these  are  quite  exceptional.  As  a 
rule,  the  early  ablation  of  missiles  and  infective 
debris  is  essential  for  rapid  and  satisfactory  recovery  ; 
it  is  absolutely  necessary  to  remove  at  the  earliest 
possible  moment  every  intra-articular  missile.  It  is 
for  want  of  understanding  of  this  fundamental  principle 
that  so  many  surgeons  at  the  front  have  given  up 
arthrotomy. 

If  we  lay  down  this  principle,  it  may  be  said  that 
an  exploratory  arthrotomy  is  the  first  step  in  the 
treatment  of  ev^ery  wound  of  the  knee. 

How  should  it  be  done  ? 

(a)  Exploration  of  the  wound  of  entry. — 
In  view  of  the  uncertaint}^  of  the  diagnosis  in  the 
first  few  hours,  and  especially  when  radiography 
is  not  available,  it  is  well  to  begin  by  making  the 
incision  at  the  wound  of  entry,  even  if  it  be  at  some 
distance  from  the  joint,  and  to  follow  it  up  and  retract 
its  edges  .  As  Gayet  has  justly  remarked,  this  method 
of  exploring  sometimes  shows  that  the  joint  has  not 
been  opened ;  and,  by  dissecting  carefully,  one  may 
bo  able  to  extract  a  missile  situated  outside  the  joint, 
though  the  latter  is  full  of  fluid. 

I  have  always  proceeded  in  this  manner  and  have 
found  it  satisfactory. 

(6)  The    Missile  lies   in   the    opening  in   the 


THE  KNEE 


209 


SYNOVIAL  MEMBRANE. — ^If  the  dissection  leads  to  an 
opening  in  the  synovial  membrane,  the  diagnosis  is 
certain  :  in  that  case  it  is  necessary  to  enlarge  the 
small  opening  freely  but  with  care,  and  see  if  the 
missile  is  there.  If  it  is  seen,  or  felt,  it  is  removed 
along  with  any  fragments  of  clothing,  the  opening  in 
the  synovial  membrane  being  enlarged  at  the  same 
time  so  as  to  enable  the  surgeon  to  ex- 
plore and  clear  out  the  joint.  Generally 
there  is  no  need  to  do  more. 

After  carefully  arresting   the   bleeding 
from  the  synovial  vessels,  which  always 
bleed  freely,  the  interior  of  the  joint  is 
dried  by  gauze,  and  the  incision 
plugged  without   draining  the 
synovial  membrane,  or,  better 
still,  when  the  patient 
can  be  kept  under  ob- 
servation :  f  o  r 
eight    or    ten 
days,    the 


Fig.   Co.— Elevated  position  of  the  knee  after  opening  the 
superior  synovial  cul-de-sac  of  the  knee-joint. 

edges  of  the  synovial  membrane  are  excised,  and  the 
joint  closed  with  catgut  sutures,  as  Delore  has  advised. 
Exploratory  arthrotomy  followed  by  complete  sutur- 
ing of  the  synovial  membrane,  which  Delore  and 
Kocher  have  described,  is  certaiinly  the  method  of 
choice  in  cases  that  are  seen  early.     But  it  should 


210     THE   TREATMENT   OF   FBACTURES 

only  be  used  when  it  is  possible  to  render  the  parts 
clean  and  Avhen  nothing  suspicious  is  left  behind  in 
the  wound  or  is  met  with  during  the  operation.  The 
more  it  is  tried  and  the  more  rapid  the  operation,  the 
more  often  will  it  be  used,  and  the  more  perfect  the 
results.  If  the  joint  is  full  of  blood,  the  same  method 
will  be  employed  ;  but  if  the  character  of  the  effusion 
is  at  all  suspicious,  it  is  more  prudent  to  drain  the 
supra-patellar  pouch  by  Jaboulay's  method.  The 
cul-de-sac  is  made  to  project  by  means  of  forceps, 
which  are  cut  down  upon,  and  a  drainage  tube  is 
inserted,  flush  with  the  joint.  The  dressing  is  com- 
pleted and  the  foot  is  well  raised,  a  posterior  plaster 
splint  immobihsing  the  joint.  The  hmb  is  supported 
on  pillows,  so  that  it  is  at  an  angle  of  45°  with  the 
trunk. 

(c)  The  Missile  is  lost  in  the  joint. — ^It  is 
essential  to  be  able  to  explore  all  the  recesses  of  the 
synovial  membrane,  so  that  nothing  suspicious  may 
escape  detection  and  removal.  The  only  efficient 
method  for  this  purpose  is  to  open  the  knee  by  the 
curved  subpatellar  incision  with  its  convexity  down- 
wards. Without  troubUng  about  the  incision  already 
made  in  order  to  follow  the  track  of  the  missile  out- 
side the  joint,  the  ligamentum  patellae  and  the  pad  of 
fatty  tissue  are  divided  transversely.  The  flap  con- 
taining the  patella  is  firmly  seized  in  catch  forceps, 
and  the  leg  is  flexed  on  the  thigh  so  that  the  cavity 
of  the  joint  can  be  thoroughly  examined.  After  re- 
moving any  foreign  bodies,  mopping  out  the  synovial 
membrane,  and  arresting  all  haemorrhage,  the  surgeon 
closes  the  joint  with  three  layers  of  sutures — serous, 
tendino-aponeurotic,  and  cutaneous.  If  there  is  a 
slight  injury  to  the  bone,  the  synovial  suturing  should 
be  so  arranged  as  to  exclude  it  from  the  joint  cavity. 
The  tendon  of  the  patella  is  carefully  united,  and  the 
wound  of  entry  and  the  track  of  the  missile  are  thor- 
oughly excised,   left  open,  and  drained  with  gauze. 


THE  KNEE  211 

If  it  is  thought  well  to  drain  the  joint,  this  may  be 
done  through  the  supra-patellar  pouch,  and  the  hmb 
well  elevated.  If  the  missile  is  not  found,  lateral 
drainage  should  be  effected,  and  the  foreign  body 
locaUsed  and  removed  as  quickly  as  possible  later. 

{d)  There  is  a  •  parietal  injury  of  the  bone. — 
This  condition  is  not  always  very  simple  :  when  the 
joint  has  been  freely  opened,  parietal  injuries,  such  as 
small  scales  of  bone  chipped  off  the  femur,  crushing 
of  the  articular  surface  of  the  tibia  (often  with  destruc- 
tion of  its  cartilage  or  jagged  fissures  of  the  patella), 
may  be  found.  Frequently  the  missile  is  still  in 
contact  with  the  broken  bone,  in  which  it  has  made  a 
sort  of  cavity  for  itself.  In  this  case  the  fragments 
ought  to  be  removed,  and  the  bone  carefully  curetted  : 
a  strand  of  aseptic  gauze  is  left  against  the  bone, 
issuing  from  one  of  the  lateral  incisions,  as  after  an 
ordinary  arthrotomy. 

If  the  operation  is  performed  early  and  properly, 
these  arthrotomies  for  extraction  of  missiles  run  a 
favourable  course,  and  the  wounds  heal  by  first  inten- 
tion with  more  or  less  perfect  recovery  of  movement  ; 
but  it  is  clear  that  such  a  method  is  one  applicable 
only  to  wounds  seen  early  before  any  sign  of  septic 
infection  is  present.  If  such  exists,  or  if  there  is 
any  doubt  about  it,  it  is  best  to  insert  drains  in 
the  lateral  incisions,  in  case  of  need  converting  the 
curviHnear  incision  into  the  H-shaped  incision  of 
resection.  But  the  ideal  method  is  to  intervene  soon 
enough,  and  with  sufficient  attention  to  detail,  so  that 
the  above-indicated  measures  may  be  possible. 

I  have  collected  notes  of  58  cases  of  early  extraction 
of  splinters  in  the  knee  joint  with  58  recoveries  (5  my 
own,  6  Delore,  5  Gayet,  6  Tisserand,  14  Santy,  10 
Bosquette.  1  Desplas,  11  Sencert).  One  of  my  per- 
sonal cases  is  the  more  striking  as  there  was  a  pene- 
trating wound  of  both  knees  with  a  double  cancellous 
fracture  of  the  upper  surface  of  the  tibia.     The  patient 


212    THE  TREATMENT  OF  FRACTURES 

recovered  without  complications,  and  with  extensive 
movements  of  both  limbs.  This  result  is  11  months 
old. 

(e)  The  Missile  has  penetrated  the  Popliteal 
SPACE  FROM  BEFORE  BACKWARDS. — ^The  Condition  is 
not  rare,  and  sometimes  injuries  of  vessels  or  nerves 
accompany  the  joint  wound.  After  arthrotomy,  only 
a  posterior  perforation  of  the  synovial  membrane  is 
found.  Generally  in  these  wounds,  action  is  confined 
simply  to  draining  the  joint,  leaving  the  missile  alone, 
unless  amputation  is  done  for  injury  to  the  vessels. 

Theoretically  it  would  appear  preferable  to  close 
the  arthrotomy  wound,  leaving  a  drainage  tube  in  the 
supra-patellar  pouch,  and  to  expose  the  vessels  and 
nerves  and  the  missile,  which  has  been  localised  by 
radioscopy,  through  an  incision  in  the  popliteal  space. 
Another  method  would  be  to  divide  the  crucial  liga- 
ments, when,  with  the  perforation  in  the  synovial 
membrane  as  a  guide,  the  missile  could  be  sought  for 
in  the  popliteal  space  from  before  backwards. 

I  have  not  seen  any  case  of  this  kind,  but  it  seems 
to  me  that  I  should  prefer  the  popliteal  method,  since 
division  of  the  crucial  ligaments  leads  to  dislocation  of 
the  knee,  which  is  dangerous  from  the  point  of  view  of 
the  ultimate  usefulness  of  the  joint. 

3.  Resection  of  the  Knee  and  Ablation  of  the  Patella. — 
When  there  is  evident  fracture,  or  when  exploratory 
arthrotomy  has  revealed  extensive  injuries  to  the 
bone,  removal  of  the  missile  and  foreign  bodies,  pre- 
ventive drainage,  and  simple  esquillectomy  do  not 
suffice.  In  order  to  save  the  patient's  life  and  to  safe- 
guard the  functional  usefulness  of  the  limb,  it  becomes 
necessary  to  perform  a  primary  resection. 

This  needs  proof. 

There  can  be  no  longer  any  doubt  about  the  necessity 

of  bone-operations  in  these  cases  :  the  gravity  of  the 

sepsis  which  occurs  at  the  seat  of  fracture  is  such, 

that  all  surgeons  who  at  the  outset  had  preconceived 


THE  KNEE 


313 


ideas  on  the  subject  have  been  quickly  converted 
to  free  esquillectomy  and  clearing  ;  but  many  are 
unwilling  to  consider  the  future  orthopsedic  result 
(Potherat,  Picque).  The  surgery  of  the  bones,  however, 
does  not  date  from 
the  present  war, 
before  which  it 
was  known  that 
atypical  resections 
give  poor  results, 
that  removal  of 
the  condyle  may 
lead  to  trouble- 
some malposition 
of  the  leg,  and 
that  to  obtain  a 
good  ankylosis, 
two  bony  surfaces 
which  have  been 
freshly  made,  not 
a  cartilaginous 
surface  and  a  re- 
cent section  o  f 
bone,  must  be 
placed  in  contact. 
Some  surgeons 
have  said  that 
union  between 
bone  and  cartilage 
has  occurred.  But 
this  is  only  ap- 
parent, because 
the  cartilage  has 
disappeared  i  n 
consequ e n c e   of 

infiammatioiii,  which  has  therefore  done,  after  much 
pain  and  danger,  what  one  cut  of  the  saw  would 
have  done  at  once,  simply  and  without  risk. 


Fig,  66, — Considerable  and  progressive 
genu  valgum  following  esquillectomy  of 
the  head  of  the  tibia  performed  at  the 
front.  The  joint  having  suppurated,  a 
vicious  ankylosis  has  been  obtained  with 
difficulty  at  the  end  of  nine  months. 
Walking  was  impossible  ;  orthopaedic  re- 
section of  the  knee  was  necessary  and 
gave  a  good  result.  It  would  have  been 
more  simple  to  perform  a  typical  resection 
at  the  outset. 


2U    THE   TREATMENT  OF  FRACTURES 


In  good  bone-surgery  it  is  absolutely  contra-indicated 
to  perform,  on  the  ground  of  economy,  what,  orthopae- 
dically  speaking,  are  illogical  operations ;  the  economical 
surgery  is  not  that  which  sacrifices  least  bone,  but 
that  which  gives  the  maximum  result  in  a  minimum 

of  time  and  risk.  At 
the  knee,  typical  resec- 
tion alone  fulfils  these 
conditions. 

If  the  patella  is  com- 
minuted, the  whole  of  it 
should  be  removed  sub- 
periosteally  ;  .  esquillec- 
tomy  is  not  sufficient. 
If  the  femur,  or  the 
tibia,  or  both,  are  in- 
volved, the  classical 
operation  of  resection  of 
both  bones  should  be 
performed  by  removing 
the  patella  and  making 
the  section  through  the 
epiphyses  if  possible. 
In  no  case  should  it  be 
limited  to  the  ablation  of 
one  condyle,  or  to  resec- 
tion of  the  tibia  only. 
Done  early,  typical  resection  gives  excellent  results, 
as  Viannay  was  the  first  to  show.  I  have  collected  37 
cases  (7  of  the  patella  and  30  of  the  femur  and  tibia) 
more  or  less  early  (of  which  3  cases  were  my  own),  with 
36  recoveries  and  1  death. 

One  can  say,  then,  that  all  non-parietal  fractures -of 
one  or  other  bone  of  the  knee  when  the  vessels  and 
nerves  are  intact  should  be  treated  by  primary  resec- 
tion of  the  patella  or  of  the  femur  and  tibia. 

4.  Amputation. — Primary  amputation  at  the  very 
outset  is  called  for  in  bony  injuries  which  are  so  exten- 


Fig.  67. — Ankylosis  after  typical 
resection  of  the  knee  for  freicture 
of  one  condyle  caused  by  shell- 
splinter. 


THE   KNEE  ^5 

sive  that  resection  is  impossible  or  dangerous.  When, 
for  example,  the  condyles  and  the  shaft  of  the  femur 
are  split  up,  when  there  are  fragments  as  high  up  as 
the  middle  of  the  bone,  which  is  not  rare  and  necessi- 
tates in  consequence  a  sacrifice  of  over  five  inches  of 
its  length,  the  indication  to  amputate  is  undoubted, 
because  the  risks  of  infection  with  so  much  loss  of 
substance  are  too  considerable,  and  in  addition  the 
only  possible  result  must  be  deplorable  from  an  ortho- 
paedic point  of  view. 

Similarly,  when  there  are  injuries  of  the  vessels  and 
nerves,  resection  is  a  gamble  ;  immediate  amputation 
is  called  for.  Functionally  it  is  incumbent  on  the 
surgeon  to  obtain  a  stump  which  is  solid  and  free  from 
pain.  If  there  is  no  hope  of  giving  the  patient  a  leg 
capable  of  carrying  the  weight  of  his  body,  the  loss 
of  the  limb  is  a  necessity  which  cannot  be  avoided. 

The  prognosis  of  these  amputations  is,  as  a  matter 
of  fact,  always  grave  :  the  patient,  who  is  in  a  state 
of  severe  shock,  affords  the  surgeon  only  the  choice 
between  interfering  at  once  and  seeing  him  die  of 
shock,  or  waiting  to  see  him  die  of  sepsis. 

In  principle,  it  is  better  to  interfere  at  once,  after 
having  tried  to  stimulate  the  patient  before  a  good 
fire,  and  in  a  warm  bed,  with  large  doses  of  camphorated 
oil.  It  has  often  appeared  to  me  that  morphine 
would  do  much  to  improve  the  condition.  Pre- 
operative transfusion,  where  possible,  is  the  heroic 
remedy  for  these  cases  of  severe  shocks. 

To  tabulate  the  foregoing :  for  articular  bullet 
wounds,  simple  immobilisation  is  suitable  ;  for  foreign 
bodies  in  the  joint,  arthrotomy  and  immediate  extrac- 
tion ;  for  .parietal  fractures,  primary  esquillectomy  ; 
for  smashed  patella,  early  excision  of  that  bone  ;  for 
fractures  destroying  the  statics  of  the  joint,  typical 
resection  ;  for  extensive  crushing  with  lesions  of  the 
vessels,  amputation. 


216     THE   TREATMENT  OF  FRACTURES 


III.   Operative  Technique 

For  the  surgery  of  the  knee,  lumbar  anaesthesia  by 
novocaine-adrenalin  is  an  excellent  method ;  in  cases 
of  shock,  and  of  crushed  joints,  it  should  certainly  be 
the  method  selected  whenever  it  is  possible  to  employ  it. 
The  directions  given  above  for  the  performance  of 
a  primary  arthrotomy  in  different  cases  suffice  for  the 
performance  of  that  operation.  I  will  only  add  that 
the  semi-lunar  cartilages  ought 
always  to  be  preserved  if  they  are 
intact,  and  that  under  no  circum- 
stances should  the  crucial  ligaments 
be  cut.  Having  said  that,  nothing 
further  remains  but  to  deal  with 
resection. 

This  should  be  performed  in  ac- 
cordance with  the  classical  direc- 
tions of  Oilier  for  a  typical  resection 
carried  out  in  healthy  tissues,  with 
a  sharp  rugine,  carefully  sparing 
the  periosteum. 

It  is  done  in  the  following  manner  : 
{a)  Incisions. — Following  a  pre- 
vious transverse  exploratory  arthro- 
tomy, as  it  often  does,  resection  will 
always  be  performed  by  an  H- 
shaped  incision  made  when  the  knee 
is  flexed.  The  transverse  branch  of 
the  incision  does  not  go  beyond  the  lateral  ligaments, 
but  is  long  enough  to  permit  the  condyles  of  the  femur 
to  be  dislocated  through  it.  From  the  ends  of  that  in- 
cision, which  is  three  and  a  half  inches  long,  two  vertical 
incisions  are  made,  the  greater  part  of  each  of  which 
is  above  the  horizontal  line,  at  either  side  of  the  patella. 
(6)  Removal  of  the  fractured  Bone. — When  the  in- 
juries have  been  well  exposed,  and  the  clots  removed, 
any  large  fragments  of  the  femur  or  the  tibia  which  are 


Fig.  68.  —  H  - 
shaped  incision  of 
typical  resection. 


THE   KNEE  217 

more  or  less  movable  are  stripped  of  their  periosteum 
with  the  cutting  rugine  after  they  have  been  fixed 
with  forceps.  This  renders  it  easy  to  preserve  their 
entire  periosteal  covering,  which  is  very  useful  for 
the  after-consolidation  of  the  limb. 

After  the  extensive  damage  done  by  the  missile  has 
been  cleared  away,  all  small  free  splinters  are  removed 
in  a  similar  manner,  and  it  is  only  when  this  process 
of  clearing  out  the  damaged  area  has  been  completed 
that  the  articular  operation  is  proceeded  with. 

(c)  Removal  of  the  Patella. — The  patella  should  be  re- 
moved with  the  rugine,  as  it  is  more  troublesome  than 
useful  in  an  ankylosed  knee  ;  the  culs-de-sac  around 
it  are'  dangerous  recesses,  from  the  point  of  view  of 
sepsis.  Sub-periosteal  removal  of  the  bone  leaves 
clean  and  smooth  surfaces  and  sound  tendon  and 
periosteum,  which  will  give  a  good  anterior  covering 
to  the  ankylosis. 

{d)  Excision  of  the  Synovial  Membrane. — Excision  of 
the  synovial  membrane  is  then  performed  as  com- 
pletely as  possible  with  forceps  and  scissors.  The 
supra-patellar  pouch  is  dissected  out  very  carefully, 
so  as  to  remove  the  whole  of  the  large  sac  and  the 
synovial  pockets  from  which  septic  absorption  might 
otherwise  take  place  ;  the  lateral  prolongations  over  the 
sides  of  the  upper  end  of  the  tibia  are  similarly  treated. 
The  posterior  ligament  of  the  joint  is  stripped  and 
identified  with  great  care,  and  the  state  of  the  vessels 
examined  through  this  structure. 

(e)  Section  of  the  Bones. — After  all  the  normal  as  well 
as  the  damaged  structures  of  the  joint  have  been 
removed,  there  remains  an  irregular  roughened  end  to 
the  femur  which  is  only  in  limited  contact  with  the 
tibial  surface,  if  at  all .  The  end  of  the  femur  is  removed 
with  the  saw,  without  taking  any  notice  of  fissures  which 
may  run  up  the  shaft  of  the  bone  ;  then  the  cartilagi- 
nous surface  of  the  tibia  is  removed  in  the  form  of  a 
thin  layer. 


318     THE   TREATMENT  OF   FRACTURES 

(/)  Fixation  of  the  Femur  and  Tibia. — This  is  not  abso- 
lutely necessary  ;  simple  juxtaposition  of  the  femur, 
by  pushing  it  against  the  cancellous  tissues  of  the 
tibia,  as  Viannay  does,  apparently  suffices  to  ensure 
bony  union.  However,  if  the  operative  conditions  are 
favourable,  and  if  one  can  count  upon  the  absence  of 
sepsis,  there  is  every  advantage  in  inserting  a  metal 
suture,  two  hooks  for  example,  as  L,  Berard  recom- 
mends. The  operator  must  see  that  his  assistant  keeps 
the  limb  in  good  position  while  the  hooks  are  being 
inserted,  or  while  the  dressing  is  being  done. 

ig)  Sutures. — When  there  is  extensive  loss  of  bone, 
the  soft  parts  are  redundant  and  form  cavities  around 
the  bones,  which  should  be  lightly  packed  with  aseptic 
gauze,  whilst  a  drainage  tube  is  inserted  on  either  side 
opposite  the  line  of  junction  of  the  bones,  at  right 
angles  to  the  long  axis  of  the  limb.  The  tendon  of  the 
patella  and  the  soft  parts  covering  the  front  and  sides 
of  the  joint  are  accurately  united  with  catgut  sutures. 
Cutaneous  sutures  should  be  inserted  in  front  only  ;  it 
will  be  well  to  put  in  none  in  the  region  of  the  wound 
made  by  the  missile,  and  simply  to  insert  some 
gauze  between  the  edges  of  the  skin  wound.  This 
avoids  infection  of  the  cellular  tissue  and  the  forma- 
tion of  pockets  of  pus  around  the  joint,  while  the  healing 
process  is  much  accelerated. 


IV.   Post-Operative  Treatment 

1.  Aiter  Arthrotomy. — ^Whatever  may  be  the  extent 
of  the  operation  performed,  tJie  knee,  under  a  dressing 
of  aseptic  gauze,  is  immobilised  in  a  posterior  moulded 
plaster  splint  of  the  usual  type,  extending  half  round 
the  circumference  of  the  limb,  and  from  the  middle  of 
the  thigh  to  the  end  of  the  foot. 

The  limb  is  raised  on  pillows  and  kept  elevated  by 
a  figure-of-eight  bandage  round  the  instep,  fastened  to 


THE  KNEE  219 

something  above  the  bed,  such  as  a  screw  in  the  ceiling, 
or  a  bar  above  the  bed. 

After  an  arthrotomy  where  sutures  without  drainage 
have  been  used,  the  first  dressing  should  be  delayed 
as  long  as  possible  if  all  goes  well ;  towards  the  seventh 
day  the  stitches  and  any  gauze  along  the  track  of 
the  missile  are  taken,  out.  If  drainage  has  been  used, 
one  can  wait  several  days.  Gayet  recommends  the 
twelfth  day  and  advises  that  elevation  of  the  limb 
should  be  continued  until  the  wound  has  closed.  As  a 
general  rule,  the  less  one  touches  the  dressing  the 
better. 

Towards  the  fifteenth  day,  gentle  movements  are 
commenced  by  making  the  patient  perform  small 
active  movements  of  the  quadriceps,  and  by  massaging 
the  limb.  This  should  be  continued  each  day,  without 
attempting  any  movement  by  instrumental  or  mechani- 
cal means.  Walking  is  allowed  at  the  end  of  three 
weeks,  if  the  movements  have  produced  no  reaction 
in  the  joint.  During  the  first  week  the  patient  wears 
a  dressing  that  exerts  pressure  on  the  joint,  preventing 
movement  of  the  knee  when  walking,  but  he  will  be 
allowed  to  walk  with  his  knee  free  in  a  month. 

If  there  has  been  injury  to  the  bone  or  the  vessels, 
immobilisation  will  be  kept  up  for  a  month. 

2,  After  Resection. — Immobilisation  has  considerable 
influence  upon  the  favourable  post-operative  progress 
of  patients  who  have  undergone  resection,  especially 
if  the  bones  have  not  been  fixed  together  by  metal 
hooks. 

In  a  resection  running  an  aseptic  course  the  question 
is  simple,  but  often,  when  there  is  free  oozing  from 
the  wound,  it  is  impossible  to  procure  permanent 
immobilisation  during  the  first  few  days.  The  best  way 
is  to  use  for  that  period  the  classical  posterior  moulded 
plaster  splint,  provided  with  an  impermeable  lining 
in  the  middle,  and  put  on  whUe  the  patient  is  still 
under    the    anaesthetic ;    or    even,    paradoxical  as    it 


220    THE  TREATMENT  OF  FRACTURES 

may  appear,  an  anterior  splint  of  the  same  material, 
embracing  half  the  circumference  of  the  limb  from 
the  top  of  the  thigh  to  the  foot.  This  is  perhaps  the 
best  method  of  securing  temporary  immobilisation, 
for  the  plaster  casing  is  easy  to  take  off  without  moving 


Lonf/ucfuf   i^u  pieJ ,  -f-  jamie . 
*■    '/i  loni/ueur  dt  Is  cutsse . 


^1. 


Fig.  69. 

the  limb,  while  it  renders  it  quite  immovable,  and  does 
not  become  softened  as  does  the  posterior  splint  (see 
fig.  63).  A  large  and  rather  wide  wooden  splint, 
slightly  hollowed  out  in  the  middle,  with  a  foot-piece, 
like  Boeckel's  splint,  reaching  as  high  as  the  middle 
of  the  thigh,  may  be  used :  this  is  provided  with  an 


Fig.  70. — Grooved  leg-splint  for  transport  of  cases  of  wounds 
of  the  knee  and  of  the  tibio-tarsal  joint. 


impermeable  covering  at  its  middle  and  is  fastened  on 
with  the  bandages. 

The  dressing  should  be  left  untouched  as  long  as 
possible,  especially  when  the  general  condition  of  the 
patient  is  good.  Generally  it  is  necessary  to  change 
the  superficial  layers  on  the  third  or  fourth  day.     It 


THE  KNEE 


221 


Fig.  71. — Interrupted  splint  which  should  never  be  used  after 
resection,  because  the  ends  of  the  bones  are  not  properly  immobi- 
lised and  backward  displacement  of  the  tibia  may  ensue.  This 
casing  should  only  be  used  after  arthrotomy,  and  only  then  when 
the  lateral  ligaments  have  not  been  destroyed. 


If  the  wound  remains 


is  well  to  change  the  deeper  ones  a  little  later.  Per- 
manent immobilisation  may  sometimes  be  effected 
as  early  as  the  eighth  day. 
aseptic,  the  simple  posterior 
gutter  splint  is  the  best  ap- 
pliance for  this  purpose,  but 
sometimes  the  wound  oozes  a 
great  deal,  and  than  the  splint 
gets  constantly  wet,  and 
softens  so  that  it  no  longer 
immobilises  the  limb,  and  has 
to  be  renewed  frequently. 
The  interrupted  plaster  ap- 
pliance seen  in  fig.  71  is  then 
a  tempting  form  of  splint  to 
use,  but  in  the  knee  it  has 
great  drawbacks :  if  used 
before  the  soft  parts  have 
shrunk,  the  plaster  bandages 
immobilise  badly  *  and  the 
popliteal  space  is  not  sup- 
ported. A  disastrous  back- 
ward   displacement    of    the 

tibia  occurs,  and  the  resulting  Fig.  72.— Bayonet-shaped 

ankylosis    is     bad     (fig.     72).      ankylosis   following   immo- 

The  interrupted  splint  there-     spl^ntTithiut""  Tpos^terSi 
fore   must   not   be   used  too     support. 


222  THE  TREATMENT  OF  FRACTURES 


early  :  if  possible,  a  fortnight  at  least  should  elapse 
before  it  is  applied.  If  it  is  necessary  to  apply  it 
sooner,  it  must  not  be  forgotten  that  the  apparatus  is 
only  temporary  ;  further,  a  small  posterior  splint  must 
always  be  added  to  the  circular  plaster  casing  round 
the  thigh  and  the  leg,  so  as  to  maintain  the  bones  in 
position.  Lastly,  it  is  necessary  that  the  plaster 
should  envelop  the  foot,  so  that  the  tibia  can  be 
fixed.  These  patients  do  better  when  the  leg  is  raised 
a  little  ;  and  an  appliance  with  supports  below  sho.uld 
accordingly  be  chosen. 

These,  remarks  will  show  that  it  is  very  difficult 
to  get  an  apparatus  which  prevents  the  knee  from 
moving,  which  is  all-important. 

The  steps  of  the  procedure  are  as  follows  : 
The  lower  limb  is  firmly  immobilised  in  extension 

by  a  reliable  assistant, 
the  patient  being  drawn 
to  the  edge  of  the  table, 
and  the  assistant  stand- 
ing between  his  thighs. 
A  large  towel  is  then 
passed  under  the  knee, 
which  is  covered  with  a 
small  aseptic  dressing 
without  any  cotton  wool. 
The  towel  supports  the 
limb  during  the  applica- 
tion of  the  first  part  of 
the  plaster. 

This  comprises  : 

(1)  A  plaster  bandage  encircling  the  thigh  from 
the  upper  third  as  far  down  as  the  dressing  at  the 
knee,  and  reaching  lower  behind  than  in  front. 

(2)  A  plaster  bandage  encircling  the  leg,  extending 
higher  behind  in  the  popliteal  space  than  in  front 
(where  it  reaches  the  tubercle  of  the  tibia),  and  covering 
the  heel.     The  foot  is  kept  at  a  right  angle  with  the  leg. 


Fig.  73. — Method  of  holding 
the  knee  during  the  application 
of  the  plaster.  An  assistant  sup- 
ports the  heel  at  the  same  time. 


THE   KNEE 


223 


(3)  Two  iron  rests  made  as  seen  in  fig.  74  :  the 
vertical  limbs  below  the  knee  are  higher  than  those 
above  it,  so  that  the  limb  is  slightly  inclined  upwards 
towards  the  foot.  These  rests  are  incorporated  in  the 
plaster  bandage,  so  as  to  form  two  lateral  supports, 
inclined  a  little  outwards. 

(4)  A  small  posterior  plaster  splint,  of  the  width  of 
the  hand,  applied  over  the  popliteal  space  between 


Fiu.  7-i.  —  Interrupted 
plaster  casing  for  use  after 
resection  :  the  numbers  give 
the  order  in  which  each  part 
of  the  splint  should  be  ap- 
l^lied. 


the  two  circular  portions  of  the  apparatus,  with  which 
it  will  be  incorporated. 

(5)  Another  bracket  can  be  incorporated  at  the 
middle  of  the  upper  surface  so  as  to  bridge  over  the 
knee  from  below  upwards,  if  it  appears  useful  :  it  is 
not  generally  used. 

When  the  splint  has  been  completed,  the  edges  of 
the  central  gap  can  be  cut  away  as  required,  and  the 
anterior  parts  of  the  foot  and  instep  are  exposed. 
The  plaster  cast  thus  made  cannot,  and  ought  not, 
to  be  kept  on  the  limb  until  the  end  of  the  case.  At 
the  end  of  a  certain  time  it  will  allow  some  play,  and 
the  leg  will  be  too  free  ;    immobilisation  is  no  longer 


224    THE   TREATMENT  OF  FBACTURES 

satisfactory,  and  displacement,  though  late,  is  still 
possible.  This  must  be  watched  for,  and  there  must 
be  no  hesitation  in  applying  a  fresh  apparatus. 

When  is  it  necessary  to  remove  the  g^uze  drains 
for  the  first  time  ?  The  drainage  tubes  can  usually 
be  removed  towards  the  sixth  day,  while  the  gauze 
is  left  in  position  and  moistened  with  a  saline  solution. 
Towards  the  eighth  day  this  gauze  is  drawn  out  little 
by  little ;  towards  the  tenth  day  it  is  completely 
removed  and  replaced  by  fresh  gauze,  either  soaked 
in  saline  solution,  or  dry,  according  to  the  condition 
of  the  wound.  Insolation  and  hot  air  treatment  are 
now  commenced.  If  everything  goes  on  well,  the 
dressing  can  be  postponed  for  a  still  longer  period, 
and  fifteen  days  may  elapse  before  it  is  renewed. 

If  there  is  the  least  rise  of  temperature  towards  the 
tenth  or  twelfth  day,  the  occurrence  of  an  abscess 
must  be  suspected :  this  is  usually  found  in  the 
calf. 

Consolidation  of  the  limb  generally  requires  three 
months,  but  walking  should  not  be  allowed  before 
four  months,  and  even  then  only  after  the  application 
of  a  plaster  bandage  thoroughly  immobilising  the 
knee. 

After  consolidation,  a  leather  covering,  moulded  to 
the  limb,  with  lateral  metal  supports,  should  be  worn 
for  a  year,  for  fear  of  secondary  deflection  of  the 
knee. 

3.  After  Ablation  of  the  Patella. — ^The  course  will 
almost  always  be  favourable.  The  first  dressing  will 
be  delayed  as  long  as  possible,  up  to  the  eighth  or 
tenth  day.  Movements  are  commenced  as  soon  as 
cicatrisation  is  complete,  that  is  to  say  about  the 
end  of  three  weeks  or  a  month.  Improvement  is 
rapid,  and  as  early  as  the  second  month  the  result 
will  be  very  satisfactory  :  extension  normal,  flexion 
half  the  normal. 


THE   KNEE  225 

V.   Evacuation  of  Patients  with  Knee  Wounds 

No  one  with  a  wound  of  the  knee  (except  with  the 
simple  perforating  bullet  wound)  ought  to  be  evacuated 
without  surgical  exploration. 

If  this  has  allowed  of  easy  extraction  of  a  missile, 
the  patient  may  be  evacuated  at  the  end  of  five  or 
six  days  in  a  plaster  casing,  if  it  is  really  necessary, 
but  it  is  better  to  keep  him  twelve  days. 

If  there  has  been  a  free  arthrotomy,  evacuation 
should  be  delayed  until  the  twelfth  day.  A  patient 
who  has  undergone  resection  ought  to  be  kept  as  long 
as  possible,  at  the  least  fifteen  days  if  all  goes  well. 
As  a  rule,  only  cases  which  have  had  a  normal  tem- 
perature for  several  days,  and  in  which  there  is  not 
much  oozing,  should  be  evacuated. 

For  evacuation,  the  limb  should  always  be  immo- 
bilised in  a  plaster  casing.  If  an  interrupted  plaster 
splint  has  not  yet  been  applied,  the  posterior  half- 
gutter  or  the  large  pelvi-pedial  splint  is  the  best 
apparatus  for  transport. 

The  journey  should  not  exceed  twenty-four  hours 
in  duration,  and  it  would  be  better  not  to  exceed 
twelve  hours. 


VI.   Treatment  of  Patients  seen  late  or  after  Evacuation 

The  patient,  correctly  operated  upon  by  arthrotomy 
or  early  resection,  generally  recovers  uneventfully. 

It  is  quite  different  with  those  who  have  been 
operated  on  insufficiently  or  not  at  all.  There  are  no 
fractures  met  with  in  war  that  are  more  difficult  to 
treat  in  the  secondary  stages. 

Let  us  lake  first  those  who  have  not  been  operated 
upon. 

1.  A  patient  arrives  on  the  second  or  third  .day  after 
the  injury  with  an  acute  suppurative  arthritis  of  the 
knee.     What  should  be  done  ? 


226     THE   TREATMENT  OF  FRACTURES 

(a)  After  determining  by  radiography,  if  possible, 
the  presence  and  the  exact  position  of  a  foreign  body 
and  the  absence  of  a  fracture,  the  orifice  of  entry  is 
freely  incised  down  to  the  synovial  membrane  : 
arthrotomy  is  then  done  by  a  vertical  incision,  four 
inches  long,  on  each  side  of  the  patella.  Through 
these  one  can  generally  extract  any  foreign  body  and 
the  missile.  Then  two  postero-lateral  incisions  are 
made  for  drainage ;  in  some  cases  {e.g.  missiles  at 
the  back  of  the  joint,  swelling,  popliteal  oedema  and 
pain)  an  incision  into  the  post-condylar  cul-de-sac 
is  made  through  the  popliteal  space.  But  the  risks 
of  popliteal  drainage  must  not  be  forgotten.  Many 
patients  treated  in  that  way  have  died  of  secondary 
haemorrhage.  The  popliteal  incision  ought  only  to 
be  an  incision  to  facilitate  search  for  the  missile,  and 
not  one  for  drainage.  To  establish  this  latter,  incision 
of  the  supra-patellar  pouch  with  the  foot  elevated 
is  the  best  method.  A  drainage  tube  should  be 
placed  in  each  opening  in  the  synovial  membrane  to 
keep  it  from  closing,  but  it  is  not  necessary  to  push 
the  tubes  deep  into  the  cavity  of  the  joint,  and  still 
less  so  to  make  them  pass  right  through  it.  The  serous 
membranes  tolerate  these  foreign  bodies  very  badly ; 
often,  after  drainage  thus  eifected,  the  temperature 
is  only  reduced  by  doing  away  with  all  the  drainage 
tubes.     No  transverse  tubes,  therefore,  should  be  used. 

If  at  the  end  of  two  or  three  days  this  drainage  has 
not  arrested  the  sepsis  and  brought  down  the  tem- 
perature, amputation  through  the  lower  third  of  the 
thigh  should  be  performed  at  oftce  before  the  patient 
has  gone  too  far  downhill.  It  should  be  done  by  the 
circular  method,  with  or  without  lateral  incisions, 
and  no  sutures  should  be  inserted.  The  muscles  are 
profoundly  septic,  infiltrated  and  cedematous ;  in 
order  to  expose  the  tissues,  the  flaps  should  be  tem- 
porarily turned  back,  for  the  least  retention  of  dis- 
charges is  very  dangerous. 


THE  KNEE  227 

Perhaps  some  of  these  cases  of  arthritis  might  be 
amenable  to  excision  of  the  synovial  membrane.*  It 
might  be  tried.  I  do  not  dare  to  recommend  it,  not 
having  had  any  experience  of  it. 

(6)  If  a  fracture,  however  limited,  exists,  resection 
of  the  knee  should  be  performed  at  once  ;  the  danger 
arises  as  much  from  osteomyelitis  as  from  arthritis, 
if  not  more.  And,  as  Poncet  taught,  the  chances  of 
saving  the  limb  are  improved  in  proportion  to  the  near- 
ness of  the  time  chosen  for  resection  to  the  onset  of 
the  infection. 

In  these  cases,  drainage  of  the  joint  is  absolutely 
without  effect ;  any  exceptions  that  can  be  cited  do 
not  invalidate  the  general  rule. 

It  is  necessary,  then,  to  treat  these  cases  of  articular 
osteitis  at  the  outset  by  resection  of  the  knee.  It  is 
often  said,  in  connection  with  these  wounds,  that 
arthrotomy,  resection,  and  amputation  ought  to  be 
done,  one  after  the  other,  when  a  primary  operation 
does  not  succeed  in  presenting  the  onset  of  infection. 
There  is  no  conception  more  illogical  or  more  danger- 
ous. Successive  operations  are  always  too  late :  it 
is  most  important  to  choose  at  the  outset  the  best 
method  of  intervention,  and  for  septic  fractures  of 
the  knee,  the  only  good  one  is  resection,  done  as  early 
as  possible.  Resection  ought  not  to  follow  arthro- 
tomy :  it  ought  to  be  preferred  to  it  whenever  there 
are  injuries  to  bone.  It  should  even  be  employed 
when  there  are  only  simple  injuries  to  the  cartilage 
(erosions  or  necrotic  ulcerations). 

L.  Berard  has  shown  cases  that  are  very  instructive 
from  this  point  of  view,  and  with  Tuffier,  Quenu, 
Viannay,  and  Gayet,  he  has  reported  cases  favourable 
to  early  secondary  resection. 

But  it  must  be  recognised,  as  all  those  who  have 
recommended  it  have  said,  that  (intra-febrile)  secon- 
dary resection  is  far  from  giving  uniform  results  :  it 
only  succeeds  if  it  is  performed  early,   for  injuries 


228     THE   TREATMENT  OF  FRACTURES 

which  are  not  too  extensive,  before  medullary  infec- 
tion has  occurred,  and  when  the  damage  to  the  soft 
parts  is  not  too  great.  Indeed,  it  is  only  justified  when 
it  does  away  completely  with  the  area  of  the  bone- 
sepsis.  Contrary  to  what  has  often  been  said,  it  is 
by  no  means  the  most  effectual  form  of  articular  drain- 
age :   so  far  from  being  tha.t,  it  does  not  drain  at  all. 

If  time  is  lost  in  performing  it,  it  is  a  great  gamble, 
and  immediate  amputation  ought  to  be  preferred  to 
such  dangerous  ultra-conservative  treatment.  In  any 
case,  if  resection  is  not  followed  by  a  rapid  fall  of 
temperature  and  a  cessation  of  the  general  symptoms 
of  sepsis,  amputation  should  be  done  forthwith. 

As  secondary  (intra -febrile)  resections  are  performed 
while  suppuration  is  at  its  height,  some  surgeons  con- 
sider it  useful  to  apply  continuous  extension  to  the 
leg,  so  as  to  maintain  a  cavity  for  drainage  between 
the  two  separated  bones.  This  is  not  a  practice  to  be 
followed  :  intense  septic  absorption  occurs  from  the 
recent  bone  sections  which  are  thus  bathed  in  pus  ; 
the  cancellous  bone  inevitably  becomes  inflamed  and 
infected,  and  even  if  the  patient  recovers  from  a  slow 
septicaemia,  the  ultimate  consolidation  of  his  limb  is 
gravely  jeopardised.  It  is  much  better  to  stake 
everything  and  do  the  operation  exactly  as  has  been 
indicated  above  for  primary  resection  ;  it  is  reason- 
able to  hope  that  infection  will  soon  cease,  and  that 
the  freshly  cut  bony  surfaces,  carefuUy  juxtaposed, 
will  not  become  fresh  centres  of  osteitis.  In  that 
event  we  may  proceed  as  if  we  were  in  the  presence  of 
a  recent  wound. 

To  sum  up :  when  we  have  to  deal  with  a  suppura- 
tive arthritis  not  yet  treated,  arthrotomy  with  drain- 
age and  resection  should  be  considered.  Arthrotomy 
with  extraction  of  the  missile  and  drainage  is  suitable 
for  simple  synovial  injuries  ;  resection  is  the  method  for 
articular  osteitis.  If  either  mode  of  treatment  proves 
a  failure,  amputation  should  be  done  Avithout  delay. 


The  knee  229 

2.  The  paiient  has  been  operated  upon  insufficiently 
or  has  been  badly  looked  after. — In  this  very  freq[uent 
case  the  patient  arrives  at  the  base  with  an  enormous 
infiltrated  knee,  oedematous,  painful,  and  riddled  with 
drainage  tubes  (I  once  found  eight,  measuring  together 
55  inches  in  length) ;  he  has  been  operated  upon 
too  late,  or  foreign  bodies  have  been  left  in  the 
joint.  His  condition  gives  the  impression  that  any 
intervention  would  be  dangerous,  that  it  might  give 
an  impetus  to  the  disease  by  provoking  an  acute 
septicaemia,  and  that  then  amputation  would  become 
necessary. 

In  short,  the  decision  is  always  a  very  delicate  one  ; 
it  should  never  be  made  off-hand,  except  where  ampu- 
tation is  obviously  urgent.  At  first  the  patients  should 
be  kept  at  rest,  and,  if  necessary,  means  adopted  to 
secure  better  immobihsation.  For  five  or  six  days,  if 
one's  hand  is  not  forced,  one  should  study  the  tem- 
perature chart,  examine  radiographs,  determine  the 
existence  of  foreign  bodies  and  define  their  precise 
position.  Once  the  necessary  information  is  in  hand, 
various  alternatives  present  themselves. 

{a)  There  are  many  cases  where  amputation  should 
be  done  without  hesitation  ;  it  should  be  done  (by  the 
circular  method  in  the  lower  third,  with  a  very  long 
skin  flap,  and  no  sutures)  when  the  temperature  is 
hectic  in  type  ;  when  the  constitutional  condition  is 
very  depressed  and  there  are  albuminuria  and  oedema  of 
the  ankle  on  the  sound  side ;  when,  by  radiographs, 
there  are  seen  to  be  extensive  bony  injuries  (femoral 
or  tibial)  ;  when  the  atrophied  thigh  shows  the  dry 
oedematous  skin  of  chronic  oedema  which  the  finger 
pits  (a  condition  in  which  phlebitis  of  the  small  veins 
round  the  joint  is  to  be  feared)  ;  when  there  are 
pockets  of  pus  behind^  in  the  thigh  and  the  leg,  which 
have  defied  well-planned  incisions ;  and,  lastly,  when 
there  is  secondary  haemorrhage. 

These  are  questions  of  degree,  and  no  absolute  rules 


230    THE  TREATMENT  OF  FRACTURES 


are  possible.     But  speaking  generally,  in  the  cases  indi- 
cated above,   there  is  everything  to  gain  by  rapid 

amputation.  It 
is  also  necessary 
to  amputate  in 
the  case  of  those 
who  have  had 
a  resection  done 
after  arthro- 
tomy  has  failed, 
and  in  whom 
the  two  succes- 
sive operations 
have  been  done 
too  late. 

(6)  There  are 
cases  where  re- 
section ought  to 
be  tried. 

These  are  the 
patients  whose 
general  con- 
dition is  still 
good ;  who  have 
no  serious  sep- 
ticaemia, and  in 
whom  the  bony 
injuries  are  evi- 
dently not  ver}^ 
extensive. 

Resection 
should  be  an 
early  operation, 
even  when  sup- 
purative arthri- 
tis is  present,  and  not  a  final  operation  after  a  failure 
by  arthrotomy. 

(c)  There  are  cases  in  which  resection  may  be  tried. 


Fig.  75. — Radiograph  showing  the  defects 
of  drainage  after  arthrotomy.  The  patient 
from  whom  it  was  taken  had  been  op'erated 
upon  primarily  at  the  front  by  double  ar- 
throtomy, four  large  drainage  tubes  being 
used.  He  was  evacuated  at  the  end  of  three 
weeks  with  an  enormous  knee,  which  was 
rounded  and  painful,  and  a  temperature 
standing  at  38' 5°. 

On  arrival,  an  exploration  with  Bergenia's 
"  vibreur  "  revealed  the  two  foreign  bodies 
shown  in  the  radiograph  :  one  was  in  the 
track  of  a  drainage  tube,  the  other  in  con- 
tact with  the  bone  at  the  very  spot  where 
the  tube  impinged.  It  was  sufficient  to  incise 
the  track  and  remove  the  projectiles.  A 
primary  operation  well  performed  would 
have  obviated  ankylosis. 


THE  KNEE  231 

These  are  cases  in  which  a  free  arthrotomy  has  not 
succeeded  in  reducing  the  temperature  and  arresting 
sepsis.  But  one  should  be  under  no  delusion  as  to 
the  efficacy  of  resection  in  these  patients.  Some  very 
remarkable  successes  have  been  reported,  but  how  many 
more  failures  have  occurred  because  the  operation  has 
been  done  too  late  !  If  in  doubt,  it  is  better  to  decide 
upon  amputation. 

{d)  There  are  cases  where  the  fractured  patella  must 
be  removed.  Simple  ablation  is  sometimes  sufficient 
to  cause  the  disappearance  of  the  septic  phenomena  ; 
the  parts  under  the  quadriceps  must  then  be  plugged 
wide  open  and  exposed  to  the  air. 

(e)  There  are  cases  where  it  is  sufficient  to  open  up 
a  collection  of  pus  which  has  passed  unnoticed,  i.e. 
an  abscess  of  the  popliteal  space  or  the  leg,  or  an 
abscess  between  the  incisions.  I  have  often  caused 
the  temperature  to  fall  and  have  stopped  the  sepsis 
by  slitting  up  the  tissues  between  one  drainage 
opening  and  another ;  in  the  track  between  them 
there  were  burrowing  abscesses,  sloughs,  or  fragments 
of  clothing. 

(/)  There  are  cases  where  it  is  necessary  to  remove 
foreign  bodies  from  a  shut-off  synovial  pocket.  This 
should  be  done  with  as  Uttle  injurj^  as  possible. 

{g)  There  are  cases  where  an  enlarged  knee  ought  to 
be  treated  as  a  tuberculous  synovitis,  by  deep  intra- 
articular cauterisations  with  the  largest  available 
cautery.  Like  Delore,  who,  with  Kocher,  has  called 
attention  to  this  condition,  I  have  seen  a  large  globular 
knee,  with  pale  granulations  and  having  all  the  appear- 
ances of  white  swelUng,  much  improved  and  eventually 
cured  after  energetic  cauterisation. 

[h)  There  are  cases  where  it  is  sufficient  to  do  away 
with  drainage  tubes  and  pack  the  drainage  incisions 
with  gauze,  so  long  as  the  temperature  is  not  raised 
and  there  is  neither  missile  nor  fracture. 

This  effect  upon  the  progress  of  wounds  caused  by 


232    THE   TREATMENT  OF  FRACTURES 

doing  away  with  drainage  tubes  is  recognised  in  the 
case  of  the  pleura  ;  a  similar  effect  is  not  surprising 
when  another  serous  membrane  is  in  question.  Small 
residual  abscesses  may  form  in  the  sinus,  but  it  will 
be  easy  to  open  them"  later  on 

[i)  Lastly,  there  are  cases  in  which  one  must  tem- 
porise, with  no  great  hope  of  final  recovery  ;  such  as 
cases  of  phlebitis,  unless  that  has  been  caused  by  the 
presence  in  the  popUteal  space  of  a  missile,  which 
should  then  be  removed  as  quickly  as  possible. 

3.  A  'patient  who  has  had  resection  done  at  the  front 
arrives  with  symptoms  of  sepsis. — Here,  again,  one 
cannot  give  any  certain  indication  ;  as  a  general  rule, 
one  will  begin  by  observing  the  effect  of  rigorous 
immobihsation  for  two  or  three  days.  If  absolute 
rest  in  a  plaster  casing  does  not  stop  the  septic 
phenomena,  one  will  look  for  pockets  of  pus  behind, 
in  the  calf,  and  in  the  hamstring  muscles,  or  even  in 
the  course  of  the  drainage  tubes.  One  will  often  find 
in  this  way  a  local  cause  explaining  an  alarming 
degree  of  sepsis,  and  recovery  can  be  easily  obtained. 

But  when  the  symptoms  of  sepsis  do  not  yield,  when 
the  constitutional  condition  is  gravely  affected,  when 
there  is  profuse  suppuration  with  considerable  separa- 
tion of  the  femur  and  tibia,  and  especially  when  there 
has  been  secondary  haemorrhage,  the  hmb  must  be 
amputated  without  delay.  It  is  the  only  means  of 
saving  Hfe. 

4.  A  patient  is  seen  late,  with  a  fistulous  ankylosis, 
or  with  marked  deviation  of  the  knee. — -These  vicious 
ankyloses  are  not  Yeiy  frequent,  but  they  exist.  I 
have  twice  seen  a  very  marked  genu  valgum  following 
an  ablation  of  the  external  condyle.  Many  cases  will 
be  seen  in  the  future,  if  the  ideas  of  certain  surgeons 
on  the  substitution  of  Hmited  esquillectomy  for  the 
typical  operation  of  resection,  without  regard  to 
orthopaedy,  prevail  at  the  front.  These  patients  ought 
to  be  treated  by  a  classical  orthopaedic  resection.     The 


THE   KNEE  233 

operation  is  easy,  in  spite  of  the  ankylosis,  for  the 
bone  is  general^  soft.  One  can  saw  close  up  to  the 
popliteal  space  ;  there,  the  section  can  be  completed 
by  fracturing  the  remaining  bone  by  slowly  flexing  the 
knee.  The  patella  is  removed  sub-periosteally,  and 
the  extremities  of  the  bones  nailed  together.  The 
operation  gives  excellent  results. 


CHAPTER    VII 


WOXJNDS  AND  FRACTURES  OF  THE  ANKLE 


I.   Anatomical  Types  and  Clinical  Course 

Bfllet  wounds  of  the  ankle  are  not  rare  in  a  war  of 
movement,  but  they  are  exceptional  in  trench  warfare, 
in  which  almost  all  wounds  in  the  lower  part  of  the 
body  are  the  result  of  spUnters  of  grenade  or  shell. 

(a)  Bullet  wounds  occur  in  considerable  variety,  of 
which  the  most 
frequent  is  the 
transverse  bullet 
track  with  a  com- 
minuted fracture 
of  the  astragalus, 
or  a  simple  per- 
foration of  the  OS 
calcis,  the  type  of 
fracture  differing 
essentially  ac- 
cording to  the 
bone  involved. 
These  wounds  are 

not     much     in-  Fig.   76. — Bullet  wound  in  the  heel   in 

fected  and  do  not     ^^^^J;^^  *^^  ^^^^°  Achiiiis.    A  sinus  with 

slight  suppuration. 

give     nse     pn- 

marily  to  severe  septic  symptoms ;  but  they  often 
develop  persistent  sinuses,  whilst  deep  in  the  bone 
a  progressive  rarefying  osteitis  develops.  This  fact 
deserves  notice,   for  in  all  other  parts  of  the   body 

234 


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^^^S 

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jfSSy'viiMlPs^ 

THE  ANKLE 


235 


Fig.  77. — ^The  same  patient  as 
fig.  76.  Development  of  a  pro- 
gressive osteitis  of  the  heel,  and 
secondary  arthritis  of  the  calcaneo- 
astragaloid  and  tibio-tarsal  joints. 


the  wounds  caused  by  long-range  bullets  usually  heal 
readily  and  without 
trouble.  I  have  been 
able  to  follow  the  course 
of  such  wounds  in  two 
cases.  In  the  case  of  a 
soldier,  the  posterior 
edge  of  whose  astra- 
galus had  been  just 
touched  by  a  bullet,  I 
thought  I  could  safely 
wait  after  having 
simply  immobilised  the 
foot  and  the  leg.  At 
the  end  of  three  months 
healing  had  not  oc- 
curred, and  the  parts 
behind  the  malleolus 
remained  swollen  and 
painful  despite  a  Hmited 
curettage,  and  so  I  ex- 
plored them  by  means 
of  a  suitably  wide  in- 
cision. Through  this 
I  removed  the  astra- 
galus, which  was  tra- 
versed from  behind 
forwards  by  a  Y-shaped 
fissure,  covered  with 
flabby  granulations . 
The  OS  calcis,  which 
was  the  subject  of  a 
rarefying  osteitis,  was 
curetted  until  the  com- 
pact bone  was  reached, 
and  after  that  recovery 
took  place  naturally  in 
three  months  (see  figs.  76,  77,  and  78).     In  the  case 


Fig.  78. — ^The  same  patient  as 
figs.  76  and  77.  Free  intervention 
at  the  end  of  the  third  month ;  re- 
section of  the  astragalus  which 
showed  a  large  fissure  from  before 
backwards  and  had  no  longer  a 
cartilaginous  covering ;  partial  re- 
section of  the  OS  calcis.  Ortho- 
paedic and  functional  results  even- 
tually good. 


•236     THE   TREATMENT  OF  FRACTURES 


of  a  patient  who  came  from  the  front  with  the  foot 

simply  immobi- 
Hsed  in  a  plaster 
case  for  a  perfora- 
tion of  the  OS 
calcis  by  a  bullet, 
sustained  seven- 
teen days  before, 
I  watched  in  ra- 
diographs the  pro- 
gressive extension 


of  a  rarefying  os- 
teitis which  had 
attacked  the  joint 
between  the  as- 
tragalus and  OS 
calcis  ;  it  became 
necessary  to  re- 
move both   bones 

sub-periosteally  in  order  to   get  heahng  (see  figs    79 

and  80). 


Fig.  79. — Gunshot  fracture  of  the  as- 
tragalus and  OS  calcis ;  progressive  rarefy- 
ing osteitis  with  slight  suppuration.  Ra- 
diograph taken  two  months  after  injury. 
The  spread  of  the  osteitis  to  the  anterior 
tarsus  is  to  be  noticed. 


(b)  The  injuries 
by  splinters  of 
grenadk  or  shell  ex- 
pose the  patient 
much  more  to  the 
inroads  of  sepsis  of 
a  more  acute  char- 
acter. Sometimes 
the  shell  splinter 
has  been  driven  into 
the  bone,  burying 
itself  firmly  in  the 
astragalus  or  the 
OS  calcis,  without 
giving  rise  to  any 
radiating  fissures, 
while  sometimes  the 


Fig.  80.— The  same  patient  as  fig.  79. 
Total  resection  of  astragalus  and  os 
calcis.  Recovery  in  three  months.  The 
radiograph  reproduced  here  was  taken 
two  months  after  operation.  The  peri- 
osteal new  growth  of  the  os  calcis  is 
easily  seen. 


THE  ANKLE  2^11 

bone  or  bones  are  traversed  by  them  from  one  end 
to  the  other.  According  to  the  direction  taken  by 
the  projectile,  there  are  different  types,  a  knowledge 
of  which  is  of  some  practical  interest. 

Injury  to  one  hone  : 

{a)  Transverse  fracture  of  the  astragalus,  with  four 
or  five  fragments.     The  most  frequent  type. 

(b)  Complete  or  incomplete  sagittal  fracture  with 
two  more  or  less  unequal  fragments. 

(c)  A  tunnel  through  the  os  calcis. 

(d)  SpHntering  of  the  posterior  part  of  the  os  calcis. 
Injury  to  more  than  one  hone  : 

[a)  Tibio-  or  fibulo-tarsal  combination.  Fracture 
of  a  malleolus  and  obhque  fracture  of  the  astragalus 
with  transverse  Assuring. 

{h)  A  combination  of  fracture  of  the  astragalus  and 
the  OS  calcis  sometimes  with  nondescript  medio-tarsal 
compHcations  (old  type  ;  involving  scaphoid-astragalus- 
os  calcis). 

As  a  rule,  in  these  different  fractures,  radiography 
gives  Httle  help  ;  a  fracture  without  displacement  does 
not  show,  and  one  always  finds  more  than  is  indicated. 

Whatever  may  be  the  anatomical  type,  rapidly  pro- 
gressive septic  infection  is  not  immediately  manifest, 
except  where  laceration  of  the  tendon  sheaths  exposes 
them  to  diffuse  phlegmonous  inflammation.  More 
often  an  acute  articular  osteitis  calHng  for  amputation 
of  the  leg  or  a  less  acute  form  becoming  chronic  maj- 
develop.  The  least  movement  is  painful  ;  there  is 
moderate  fever  (38-6°C.  =10r5°F.).  The  general  health 
gradually  becomes  bad  and  the  patient  assumes  the 
characteristic  appearance  of  a  man  suffering  from 
septic  absorption  without  much  suppuration.  The 
aspect  is  that  of  toxaemia  ;  the  skin  is  dry  and  yellowish- 
white,  the  eyes  bright,  the  eyelids  rather  swollen, 
the  features  drawn,  the  expression  anxious*;  until, 
finally,  in  despair,  one  peiforms  amputation  of  the  leg. 

(c)  Partial   destruction   of  the   Foot. — A    moderate- 


238     THE   TREATMENT  OF  FRACTURES 

sized  shell  -  splinter  or  an  explosion  of  a  hand- 
grenade  striking  the  foot  tears  away  part  of  the  foot, 
a  condition  difficult  to  describe  because  the  appear- 
ances are  so  varied.  Through  the  gaping  skin  wound 
are  seen  torn  tendons,  vessels  twisted  and  no  longer 
bleeding,  or  else  gaping  and  giving  rise  to  severe 
haemorrhage,  joints  opened  and  bones  broken  or 
crushed,  notably  the  os  calcis,  the  posterior  part  of 
which  is  often  torn  away.  Unless  one  intervenes  at 
once,  rapid  and  disastrous  sepsis  sets  in  and  necessi- 
tates amputation  on  the  second  or  third  day. 

II.  Primary  Therapeutic  Indications 

In  all  these  wounds,  if  one  waits,  infection  is  a 
toregone  conclusion :  it  is  absolutely  necessary  to 
perform  a  complete  clearing  operation  as  rapidly  as 
possible,  removing  foreign  bodies,  sloughs,  and  splinters 
of  bone. 

Except  in  the  wounds  with  punctiform  openings, 
which  are  very  rare,  and  amenable  here  as  elsewhere 
to  simple  immobilisation,  intervention  is  a  necessity. 
What  must  be  done  ?  Three  operative  methods  are 
possible. 

1.  Clearing  out  the  wound  combined  with  Esquil- 
lectomy.—  This  operation  is  suitable  for  : 

{a)  Blind  wounds  caused  by  shell-splinters  where 
the  missile  is  fixed  in  the  bone  and  there  are  no  radiating 
fissures.  In  these  cases  early  removal  of  the  foreign 
body,  followed  by  curetting  of  the  bony  cavity,  short 
of  a  sub-cartilaginous  hollowing  out  of  the  head  and 
body  of  the  astragalus,  suffices  to  prevent  sepsis, 
and  even  to  arrest  it  if  it  has  already  set  in.  If  the 
osseous  lesion  turns  out  to  be  more  considerable  than 
appears  at*  first,  and  the  curetting  happens  to  reach 
the  cartilaginous  covering  of  the  head  of  the  astragalus 
for  example,  the  cartilage  should  be  clipped  away. 
It  is  not  necessary  to  undertake  a  more  complex  opera- 


THE  ANKLE 


239 


tion,  since  simple  resection  of  the  head  of  the  astragalus 
gives  satisfactory  results  (Oilier)  ;  the  loss  of  sub- 
stance is  made  good  by  fibrous  tissue  interspersed  with 
bone  particles  ;  the  scaphoid  is  carried  backwards, 
and,  except  for  some  diminution  in  length  of  its  inner 
side  and  an  increase  in  the  height  of  the  arch,  the 
shape  of  the  foot  is  not  materially  altered. 

When,  on  the  contrary,  the  curetting  of  the  astra- 
galus leads  to.  the  loss  of 
the  whole  of  the  posterior 
part  of  the  bone,  it  is  better 
to  perform  complete  exci- 
sion of  the  astragalus :  unless 
this  is  done  the  tibio-fibular 
arch  loses  its  support  and 
comes  down  upon  the  os 
calcis,  the  head  of  the  as- 
tragalus is  thrust  up  over 
the  anterior  edge  of  the 
medio-tarsal  joint,  the  or- 
thopaedic result  is  bad,  and 
the  foot  is  ankylosed  and 
painful.  There  is  thus  no 
economy  in  doing  a  resec- 
tion confined  to  the  body 
of  the  astragalus. 

In  the  case  of  the  os  cal- 
cis, on  the  contrary,  hollow- 
ing out  of  the  bone  is  the  operation  of  choice,  not 
only  in  blind  wounds  with  the  missile  in  situ,  but  also 
in  the  majority  of  the  complete  fractures  caused  by 
shell-splinters.  I  have  several  times  scraped  out 
the  whole  of  the  upper  part  of  the  bone  for  severe 
fractures,  preserving  only  its  plantar  surface,  the 
great  tuberosity,  and  the  insertion  of  the  tendo 
Achillis.  The  results  have  always  been  perfect  from 
the  orthopaedic  point  of  view.  Complete  resection  is 
only  rarely  indicated,  but  in  a  case  of  total  destruc- 


FiQ.  81. — Result  seven 
months  after  a  sub-periosteal 
resection  of  the  os  calcis  for  a 
complicated  firacture  duo  to 
accident.  The  operation  was 
done  four  years  ago ;  the 
functional  resvilt  is  excellent. 


240     THE   TREATMENT  OF  FRACTURES 


tion,  there  need  be  no  hesitation  in  employing  it  ; 
in  spite  of  the  many  inconveniences  of  which  we  shall 
speak  (p.  244 ),  it  is  a  very  good  operation.  I  was 
once  able  to  follow  up  a  patient  from  whom  I  had 
removed  the  whole  of  the  bone  for  a  comminuted 
fracture :  the  periosteum  had  regenerated  a  solid 
calcaneal  mass  of  bone,  the  work  of  the  foot  was  well 
performed,  walking  was  painless,  and  there  was 
scarcely  any  lame- 
ness. I  am  at  the 
present  moment 
treating  a  patient 
of  Gazet's  in  whom 
the  result  is  excel- 
lent, in  spite  of 
great  loss  of  the 
tibial  soft  parts. 

Esquillectomy  is 
also  well  suited  to 
certain  combined 
injuries  of  the  tibia 
and  astragalus  : 
this  will  be  con- 
sidered in  connec- 
tion with  resection. 
In  short,  atypical 
partial  operations 
are  indicated  for 
blind  fractures  with  the  missile  in  situ,  for  injuries 
localised  to  the  head  of  the  astragalus,  and  for  frac- 
tures of  the  OS  calcis. 

2.  Sub-periosteal  Resection. — In  the  ankle,  resection 
really  means  ablation  of  the  astragalus,  rather  than 
ablation  of  the  astragalus  plus  resection  of  the  articular 
surfaces  of  the  tibia  and  fibula.  In  military  surgery 
it  is  the  same  thing :  one  should  never  do  complete 
tibio-tarsal  resection,  that  is  to  say,  remove  the 
astragalus  and  the  tibio-fibular  joint,  any  more  than 


Fig.  82. — Sub-periosteal  resection  of 
the  OS  calcis  for  fracture  by  shell-splinter. 
The  periosteal  regrowth  of  the  calcis  is 
well  shown.  Four  months  afterwards 
cicatrisation  was  complete  :  the  astra^ 
galus  was  up  against  the  arch  ;  the  os 
calcis  is  represented  by  a  dense  layer 
of  periosteum. 


THE  ANKLE 


241 


one  should  remove  both  os  calcis  and  astragalus  for 
calcaneo-astragaloid  injuries.  As  Oilier  has  clearly 
established  in  tuberculous  lesions,  the  cavity  made 
by  sub-periosteal  resection  of  the  astragalus  gives 
sufficient  room  to  carry  out  by  means  of  local  opera- 
tions efficient  treatment  of  fractures  involving  the 
malleoli,  the  astragalus,  and  os  calcis. 

Ablation  of  the  astragalus  is  indicated,  then : 
ia)  In  Fractures  limited  to  the  Astragalus. — Im- 
mediate excision  of  the  astragalus  is  the  method  of 
c  h  o  i  c  e  in 
these  cases, 
whatever  be 
the  agent 
causing  the 
fracture,  be- 
cause it  pre- 
vents  all 
p  o  s  s  i  b  i  lity 
of  osteo- 
articular  in- 
fection, and 
also  because 
it  is  the  best 
means  of 
treating  the 
fractures 
the  m  selves. 
In  peace-time 

the  conclusion  had  been  arrived  at  that  immediate 
excision  of  the  astragalus  was  the  ideal  method  of 
treatment  for  simple  fractures,  because,  if  left  to 
themselves,  they  generally  resulted  in  painful  anky- 
losis. In  military  surgery  there  is  no  reason  why 
it  should  be  otherwise  :  a  frar':Tire  of  the  astragalus  is. 
strictly  speaking,  intra-articular,  and  its  union  is 
exposed  to  the  same  painful  disadvantages  as  is  the 
union  of  a  simple  fracture. 


Fig.  83.— Primary  resection  of  the  astragalus 
for  fracture  by  bullet.  Aseptic  course.  Re- 
covery in  one  and  a  half  months.  Very  satis- 
factory result  at  the  end  of  six  months ;  able  to 
walk  with  ease  and  without  pain. 


242     THE   TREATMENT  OF  FRACTURES 


I  have  performed  primary  excision  of  the  astragalus 
on  foiir  occasions  for  fracture  by  bullets,  with  excellent 
results. 

(b)  In  Fractures  of  the  Astragalus  and  Malleoli 
combined. — Immediate  excision  of  the  astragalus 
allows  one  in  these  cases  to  deal  very  sparingly  with 
the  malleoli,  which  is,  orthopaedically  speaking,  very 

important ;  indeed,  one 
should  never  lose  sight 
of  the  fact  that  it  is  far 
preferable  to  remove  the 
astragalus  and  preserve 
the  malleoli,  than  to.  sac- 
rifice the  malleoli  in 
order  to  preserve  the 
astragalus.  The  loss  of 
the  internal  malleolus, 
if  ankylosis  of  the  as- 
tragalus to  the  bones  of 
the  leg  or  the  newly 
formed  periosteal  bone 
is  not  obtained,  is  ac- 
companied by  displace- 
ment of  the  foot  upwards 
and  inwards  ;  resection 
of  the  external  malleolus 
is  followed  by  rotation 
of  the  foot  outwards,  and 
walking  is  very  difficult. 
Excision  of  the  astra- 
gives   a    very   satisfactory 


Fig.  84.— Fracture  of  the  as- 
tragalus and  OS  calcis  by  a  shell- 
splinter.  Primary  resection  of 
the  whole  of  the  former  and  part 
of  the  latter ;  the  posterior  part  of 
the  OS  calcis  with  the  insertion  of 
the  tendo  Achillis  was  left.  Or- 
thopaedic and  functional  result 
after  nine  months  excellent.  The 
patient  had  at  the  same  time  a 
fracture  of  the  opposite  tibia 
which  was  treated  by  primary 
sub-periosteal  esquillectomy  and 
healed  without  sepsis. 

galus,  on  the  other  hand, 
functional  result. 

If,  then,  a  missile  has 
and  has  then  penetrated  the  astragalus,  this  latter  bone 
must  be  resected,  but  the  treatment  of  the  malleolar 
injury  must  be  limited  to  clearing  it  out,  by  which 
means  the  maximum  of  bone  and  periosteum  is 
preserved. 


broken   up  one  malleolus 


THE  ANKLE 


243 


The  excellent  drainage  provided  by  ablation  of  the 
astragalus  will  prevent  or  check  the  inroads  of  sepsis, 
and  the  malleolar  fracture  should  run  an  uneventful 
course.  The  longitudinal  splinters  fuse  together  and 
make  a  rigid  pillar  of  bone. 

(c)  In  Fractures  of  the  Posterior  Tarsus. — When  the 
bodies  of  the  astragalus  and  os  calcis  are  involved, 
when  the  astragalus  is  broken  into  four  or  five  frag- 
ments and  lies  upon  an  os  calcis  which  has  been  reduced 
to  a  pulp,  it  is  necessary  to  abstain  both  from  ampu- 
tation of  the  leg,  which 
is  performed  too  often 
in  these  cases,  and  from 
a  typical  resection  of 
the  posterior  tarsus. 

By  removing  the  as- 
tragalus in  the  first 
place,  and  then  expos- 
ing the  OS  calcis  at  the 
seat  of  election,  enough 
room  is  obtained  to 
scrape  away  completely 
the  cancellous  tissue  of 
the  OS  calcis,  while  pre- 
serving all  the  sur- 
rounding healthy  parts 
which  will  effectually 
resist  infection  and  give  a  solid  sole  capable  of  main- 
taining the  shape  of  the  foot.  The  clearing  out  of 
the  seat  of  the  fractures  ought  to  be  done  with  great 
attention  to  detail,  so  as  to  avoid  the  interminable 
suppuration  which  follows  the  retention  of  fragments 
which  have  been  overlooked ;  in  practice  it  will 
almost  always  be  possible  to  preserve  the  posterior 
lamella  of  bone  into  which  the  tendo  Achillis  is  inserted 
and  the  shell  of  compact  bone  on  its  plantar  surface. 
Thus  we  shall  have  what  Oilier  called  the  "  anse 
calcaneenne,"  which  forms  the  basis  of  a  firm  periosteal 


Fig.  85. — Fractiore.  of  the  astra- 
galus and  of  the  articular  surface 
of  the  OS  calcis.  Primary  resection 
of  the  astragalus  and  curettage  of 
the  OS  calcis.  Preservation  of  the 
"anse  calcaneenne."  Orthopaedic 
ftmctional  result  after  eleven 
months  excellent. 


244     THE   TREATMENT  OF  FRACTURES 

bone  formation  assuring  perfect  solidity  to  the  foot, 
and  enabling  it  to  retain  its  normal  shape.  The  same 
plan  is  followed  with  the  great  tuberosity,  which 
should  always  be  spared  if  possible,  as  it  protects  the 
articulation  with  the  cuboid.  It  is  most  important 
to  think  out  these  orthopaedic  details  before  deciding 
to  intervene  in  these  complicated  cases,  for  typical 
ablation  of  the  os  calcis  is  a  proceeding  which  makes 
a  great  alteration  in  the  support  and  movements  of 
the  foot,  whether  from  the  point  of  view  of  muscular 
action  or  of  the  movements  of  the  anterior  tarsal 
joints.  Oilier  said  little  on  this  matter.  It  is  true, 
that  before  he  would  admit  that  the  result  of  an 
ablation  of  the  os  calcis  was  excellent,  he  insisted  that 
the  patient  should  be  able  to  walk  without  appliance 
and  in  the  normal  manner.  The  same  standard 
should  be  required  to-day.  It  is  for  this  reason  par- 
ticularly that  the  plantar  surface  of  the  os  calcis  and 
the  insertion  of  the  tendo  Achillis  should  be  preserved. 
If  this  can  be  done,  the  result  will  be  good  in  the 
sense  that  Oilier  used  the  term,  even  when  the  injury 
has  been  very  extensive.  For  my  own  part,  I  have 
obtained  the  best  possible  results  from  the  method 
outlined  above  in  cases  in  which  the  destruction  of 
the  astragalus  and  os  calcis  seemed  to  demand  ampu- 
tation of  the  foot  with  a  heel  flap.  The  procedure 
would  be  the  same  in  injuries  that  extend  to  the  fore 
part  of  the  foot,  but  do  not  call  for  total  excision  of 
the  tarsus.     We  shall  speak  of  this  again  farther  on. 

3.  Amputation. — This  is  only  indicated  if  there  is 
an  insufficiency  of  the  soft  parts,  especially  on  the 
sole  or  the  heel  :  the  injuries  to  the  tarsal  bones, 
however  extensive  they  may  be,  ought  never  to  cause 
the  surgeon  to  amputate,  if  the  condition  of  the  soft 
parts  allows  any  hope  of  the  movements  of  the  foot 
being  eventuallj^-  retained.  Some  means  of  preserving 
the  foot  can  always  be  found,  if  this  condition  is 
fulfilled :  excision   of  the   astragalus   combined   with 


THE   ANKLE  245 

esquillectomy  of  the  bones  of  the  leg,  or  with  typical 
resection  of  the  tibia  and  fibula,  or  total  excision  of 
the  posterior  tarsus,  especially  if  performed  at  once, 
will  avoid  the  sacrifice  of  the  foot  in  what  are  appar- 
ently the  gravest  cases,  even  if  the  internal  plantar 
vessels  have  been  severed. 

But,  on  the  other  hand,  if  there  is  not  sufficient  skin 
below  and  on  the  inner  side,  if  the  tendons  are  lacer- 
ated, if  the  posterior  tibial  artery  and  the  nerves 
are  cut,  amputation  low  down  will  be  better  both  as 
regards  the  present  and  the  future. 

Farther  on  we  shall  discuss  the  method  of  amputa- 
tion that  should  be  chosen. 

m.  Operative  Technique 

1.  Modes  of  Access. — A  precise  knowledge  of 
these  is  essential  from  the  point  of  view  of  the  restora- 
tion of  function.  Exposure  of  the  astragalus  ought 
to  be  made  by  incisions  which  do  not  sacrifice  any 
tendon.  Whether  it  be  for  removal  of  a  foreign  body 
or  for  ablation  of  the  astragalus,  the  bones  will  be 
approached  through  the  classical  incisions,  unless 
there  is  a  special  indication  for  using  the  wound  of 
entry  of  the  missile  ;  in  all  cases  the  latter  will  always 
be  cleared  and  explored. 

The  classical  incisions  designed  to  avoid  the  tendons 
should  be  well  known  :  there  are  two,  an  external 
and  an  internal.  The  foot  being  extended  on  the 
leg  and  adducted,  the  external  and  more  important 
incision  is  commenced  two  inches  above  the  malleolus, 
at  the  internal  edge  of  the  fibula  and  outside  the 
peroneus  tertius ;  it  runs  down  to  the  level  of 
the  cuboid  in  the  direction  of  the  commissure  of  the 
fourth  and  fifth  toes  ;  perpendicular  to  it,  a  short 
incision  about  li  in.  long  descends  to  the  tip  of  the 
external  malleolus.  The  incision  should  be  free, 
but  not  deep  enough  to   divide  the  tendon  of  the 


2  46  THE   TREATMENT  OF  FRACTURES 


Fig.  86. — External  incision  for 
resection  of  the  astragalus. 


peroneus  tertius,  and  especially  that  of  the  peroneus 
brevis  below  the  malleolus.  This  incision  opens  the 
inferior  tibio-fibular,   the  tibio-tarsal  and  astragalo- 

scaphoid     articula- 
tions, and  it  renders 
easy    the     detach- 
ment of  the  anterior 
ligament      between 
the  fibula  and  the 
astragalus,  and  the 
clearing  of  the  neck 
of    the     astragalus 
and   the  ligaments 
uniting  the  head  of 
that    bone   to   the 
scaphoid. 
The  second  incision,  antero-intemal,  passes  round 
the  internal  malleolus  and  terminates  a  Kttle  behind 
its  tip.     From  the  centre  of  this  incision,  which  corre- 
sponds to  the  base  of  the  malleolus,  another  incision 
is     made     down- 
wards    and     for- 
wards   as    far    as 
the    level    of    the 
astragalo-scaphoid 
joint   without 
going  beyond  the 
tibialis  anticus 
tendon ;     this 
allows    the    tibio- 
tarsal    and   astra- 
galo-scaph  oid 
joints    to     be 
opened.     It  is  un- 
necessary to  make  any  posterior  incisions  [for  drain- 
age.    As  soon  as  the  incisions  have  been  carried  down 
to  the  bone,  the  work  of  the  rugine  should  commence  ; 
it  ought  to  be  used  with  much  care,  and  by  its  means 


Fig.  87. — External  elbowed  incision  for 
exposure  and  resection  of  the  os  calcis. 


THE  ANKLE  247 

the  insertions  of  the  hgaments  into  the  periosteum 
are  preserved,  and  one  does  not  lose  one's  way  among 
the  tendons  and  muscles.  When  the  bone  has  thus 
been  removed  hy  means  of  the  rugine,  nothing  is  easier 
than  to  explore  the  walls  of  the  gaping  cavity. 

Exposure  of  the  Os  Calcis.—The  incision  should  be 
free  and  L-shaped,  following  the  external  border  of 
the  tendo  AchilHs  and  then  the  outer  edge  of  the  sole. 
The  tendons  of  the  peronei  are  drawn  upwards  and 
forwards  by  retractors,  and  in  this  manner  enough 
room  is  obtained  without  endangering  neighbouring 
tissues,  so  that  it  is  easy  to  do  all  that  is  necessary  to 
the  OS  calcis.  The  principle  underlying  these  opera- 
tions is  to  do  only  atypical  operations  with  the  rugine 
and  curette,  sparing  if  possible  the  "anse  calcaneenne," 
in  preference  to  complete  resections. 

2.  Amputation. — ^The  systematic  resort  to  early 
resection  much  reduces  the  indications  for  amputation. 
Should  this  appear  necessary,  one  of  the  four  following 
methods  should  be  employed,  according  to  circum- 
stances. 

Suh-astragaloid  disarticulation,  which  is  sometimes 
possible  when  much  of  the  plantar  skin  remains. 

Pirogoff^s  amputation  through  the  os  calcis,  or  one 
of  its  modifications,  whenever  the  condition  of  the 
bone  will  allow. 

Syme's  tibio-tarsal  disarticulation,  or  that  of  J.  Roux 
by  an  internal  flap,  with  decortication  of  the  os  calcis 
by  means  of  the  rugine,  so  as  to  leave  the  periosteum 
on  the  shell  of  bone,  which  will  form  an  osteo-plastic 
centre,  as  recommended  by  Oilier. 

Guyon's  supra-malleolar  amputation  with  a  posterior 
flap. 

Amputation  in  the  lower  third  of  the  leg. — In  practice 
the  first  two  forms  of  amputations  are  seldom  indi- 
cated in  injuries  of  the  posterior  tarsus  ;  when  a 
Pirogoff  or  a  Syme  is  possible,  excision  of  the  posterior 
tarsus  is  generally  equally  so,  and  that  operation  is 


248     THE   TREATMENT  OF  FRACTURES 

always  preferable.  Still,  whenever  an  amputation 
with  a  heel  flap  is  practicable,  it  ought  to  be  chosen, 
its  functional  results  being  so  satisfactory. 

If  the  injuries  are  very  considerable  there  is  no  need 
to  keep  to  one  of  the  set  operations  and  so  to  ampu- 
tate high  up  the  leg.  Irregular  atypical  flaps  should 
be  cut  at  the  level  of  the  wound,  and  the  bone  should 
be  sawn  a  Uttle  higher  up  than  is  necessary  from  the 
point  of  view  of  length  of  the  skin  flaps,  since  the 
wound  must  be  left  open  and  without  sutures. 

Sometimes  sutures  may  be  inserted  after  some  days, 
but  it  is  always  necessary,  in  spite  of  this,  to  expect 
considerable  retraction  of  the  skin. 

IV.  Post-Operative  Treatment 

1.  After  simple  Curetting  of  the  bone  (Astragalus  or 
Os  Calcis). — ^It  is  suflicient  to  place  a  gauze  wick  in 
contact  with  the  bony  cavity,  and  to  immobihse  the 
limb  in  good  position  in  the  simple  posterior  plaster 
spUnt  extending  above  the  knee,  as  described  on 
page  220  ;  this  should  be  removed  at  each  dressing, 
and  must  be  remade  if  the  plaster  becomes  soft.  If 
necessary,  its  place  maybe  taken  by  an  iron  wire  splint. 
The  first  dressing  should  be  left  undisturbed  for  a  week 
at  least,  if  there  is  no  rise  of  temperature  ;  then  the 
gauze  drain  is  abandoned,  and  only  infrequent  dress- 
ings are  required.  Passive  movements  are  commenced 
towards  the  tenth  day.  Walking  with  the  weight 
borne  direct  upon  the  ground  will  not  be  allowed  for 
at  least  a  month.     Recovery  is  generally  very  rapid. 

2.  After  simple  Astragalectomy. — ^The  joint  cavity 
is  lightly  filled  with  aseptic  gauze  ;  a  strand  of  that 
material  is  introduced  through  each  incision,  so  that 
they  meet  one  another.  It  is  wrong  to  pass  a  drain 
of  this  type  through  from  one  side  to  the  other  ;  its 
removal  is  much  more  painful.  It  is  unnecessary  to 
insert  drainage  tubes.     Too  much  dressing  must  not 


THE  ANKLE 


249 


Fig.  88. — Interrupted  plaster  casing 
after  resection  of  the  astragalus. 


be  put  on  before  applying  the  first  bandage,  and  the 
dressing  will  not  have  been  well  applied  unless  the 
foot  remains  in  good  position,  without  the  least 
tendency  to  dis- 
placement, when 
the  bandage  has 
been  applied 
round  the  foot 
and  carried  up 
to  the  middle  of 
the  leg. 

ImmobiHsation 
will  then  be  ef- 
fected by  the 
classical  posterior 
plaster  spUnt,  as 
above.  One 
should  wait  as 
long  as  possible 
before,  doing  the  first  dressing — ten  days  if  all  goes 
well.     If,  on  the  first  day,  the  blood-stained  discharge 

has  soiled  all 
the  dressings, 
only  the  super- 
ficial layers  need 
be  changed,  for 
it  is  very  im- 
portant not  to 
disturb  the 
wound,  and  to 
give  the  tissues 
time  and  oppor- 
tunity to  organ- 
ise their  defence 
and  commence 
their  repair. 
Toward  the  tenth  day  the  gauze  drains  are  removed 
and  replaced  by  others. 


Fig.  89. — ^Interrupted  plaster  casing  after 
resection  of  the  os  calcis. 


250     THE   TREATMENT  OF  FRACTURES 

If  any  abnonnal  oozing  necessitates  frequent  changes 
of  dressings,  an  interrupted  plaster  casing  must  be 
provided,  but  this  should  not  be  regarded  as  the  best 
apparatus  since  it  does  not  immobilise  well,  especially 
at  the  instep,  and  it  requires  more  supervision  ;  in 
short,  it  ought  only  to  be  used  on  account  of  free 
oozing,  or  after  the  ligaments  round  the  joint  have 
recovered  their  power. 

This  apparatus  is  made  in  the  following  manner  :  a 
circular  bandage  surrounds  the  lower  half  of  the  leg 
as  far  as  the  malleoli  ;  a  second  embraces  the  front 
half  of  the  foot  as  far  down  as  the  toes.  These  two 
portions  are  united  either  by  a  single  bracket  of 
hoop-iron  in  the  long  axis  of  the  leg  and  foot  or  by 
two  of  them  appUed  laterally  or  else  posteriorly,  when 
they  act  as  supports. 

When  the  plaster  is  dry  the  heel  must  be  carefully 
supported  by  means  of  a  wide  bandage  after  each 
dressing,  and  this  should  be  converted  into  a  sort  of 
hammock  fastened  to  the  anterior  bracket  until  the 
front  part  of  the  foot  becomes  fixed  by  its  ligaments. 

During  the  whole  of  the  post-operative  treatment 
constant  care  is  required  to  keep  the  foot  in  correct 
position.  If  the  foot  rests  too  much  on  the  heel,  it 
is  pushed  forwards ;  if  it  is  not  properly  supported,  it 
slips  backwards  ;  if  the  sole  is  not  firmly  maintained 
in  its  normal  position,  it  tends  to  be  rotated  inwards 
into  a  position  of  varus.  Unless  he  is  carefully  watched, 
the  patient  will  have  a  deformed  foot,  and  it  will  be 
difficult  to  correct  this  deviation  when  the  plaster  is 

left  off. 

When  a  tendency  to  deviation  is  noticed,  a  fresh 
plaster  casing  should  be  appHed  to  correct  it  without 
delay  under  chloride  of  ethyl  anaesthesia.  This  is 
better  than  the  classical  traction  upon  the  foot  with 
an  elastic  bandage,  which  patients  usually  omit  to  use 
and  which  produces  little  result. 

Attention  should  also  be  paid  to  the  toes  :    they 


THE  ANKLE  251 

should  be  frequently  moved,  to  counteract  stiffness,  as 
they  have  a  pernicious  tendency  to  assume  the  shape 
of  a  plantar  claw. 

Walking  is  not  allowed  until  the  end  of  three  months, 
when  a  plaster  support  is  employed  while  waiting 
for  the  permanent  support  (a  boot  with  lateral  irons 
extending  to  just  below  the  knee).  There  should 
never  be  any  hurry  in  seeking  for  mobility,  which  is 
almost  always  recovered  without  trouble ;  it  should 
only  be  obtained  after  the  parts  have  become  firm. 

The  same  care  will  be  required  after  a  tjrpical  resec- 
tion of  the  OS  calcis,  but  the  post-operative  super- 
vision should  be  more  prolonged,  and  walking  should 
only  be  permitted  after  a  longer  interval  (four  or  five 
months). 

3.  After  a  complex  Resection. — ^The  line  to  follow 
is  the  same,  but  immobilisation  should  be  of  longer 
duration.  If  the  malleoli  have  been  involved  in  the 
operation,  their  solidification  and  regeneration  will  be 
a  lengthy  proceeding.  Until  the  parts  have  become 
quite  firm  the  patient  must  not  be  allowed  to  walk. 
If  the  parts  do  not  become  firm,  it  is  better  to  try 
to  get  bony  union  between  the  os  calcis  and  the  tibio- 
fibular arch,  if  necessary  by  curetting  the  cartilage 
from  it.  This  will  take  at  least  four  or  five  months, 
and  it  must  not  be  expected  that  these  patients  will 
be  able  to  walk  without  a  stick  before  eight  or  ten 
months. 

It  is  the  same  in  resection  of  the  astragalus  and  os 
calcis. 

4.  After  Amputation. — ^The  operation  is  completed 
ivithout  suturing  the  flaps,  but  at  the  end  of  a  few 
days,  when  there  is  no  longer  fear  of  infection,  stitches 
may  be  inserted.  One  or  two  can  be  used  to  bring 
the  plantar  flap  into  apposition  with  the  anterior 
surface  of  the  leg,  and  in  this  manner  the  convalescence 
may  be  shortened  and  a  better  stump  obtained. 


252    THE  TBEATMENT  OF  FRACTURES 

V.   Evacuation  of  Patients  with  Ankle  Wounds 

These  are  generally  capable  of  speedy  evacuation  : 
a  patient  operated  on  by  localised  curetting  of  a  bone 
can  be  put  on  the  rail  forty-eight  hours  afterwards  ; 
a  resection  of  the  astragalus,  at  the  end  of  from  six 
to  eight  days  ;  a  comphcated  resection,  at  the  end  of 
from  ten  to  twelve.  In  cases  of  extreme  urgency  all 
of  them  can  be  evacuated  at  the  end  of  forty-eight 
hours  much  more  easily  than  if  they  had  not  been 
operated  upon. 

For  the  journey,  the  ideal  apparatus  is  the  posterior 
plaster  casing,  which  immobilises  well,  does  not  hurt, 
and  allows  easy  supervision  of  the  toes  and  the  leg. 

VI.  Treatment  of  Patients  seen  late  or  after  Evacuation 

The  patient  operated  upon  early  by  Umited  esquillec- 
tomy  for  injury  of  the  bone,  or  by  resection  for  an 
extensive  fracture,  heals  rapidly  and  without  incident. 
It  is  otherwise  when  the  prophylactic  operation  has 
been  omitted  or  has  been  done  insufficiently. 

1.  A  Patient  is  seen  after  a  long  interval. — 
A  patient  seen  after  twenty-four  hours  or  still  later, 
not  treated  at  all,  or  insufficiently,  usually  shows  signs 
of  suppurative  arthritis  of  the  ankle  with  severe  con- 
stitutional disturbance,  an  enormously  swollen  foot 
with  Hvid  patches  Up  the  leg,  and  oedema  of  the  front 
of  the  foot  and  the  toes.  Examination  is  impossible 
as  the  pain  is  too  acute.  Suppurative  arthritis  of  the 
ankle  is  amenable  to  immediate  surgical  measures 
which  will  probably  take  the  form  of  an  arthrotomy 
by  the  two  exploratory  incisions  described  above,  to 
which  should  be  added  two  counter-openings  behind 
the  malleoli  for  drainage  between  the  bone  and  the 
tendo  AchilHs.  The  presence  of  the  posterior  tibial 
vessels  on  the  inner  side  must  not  be  forgotten. 

This  arthrotomy  may  suffice,  but  as  we  are  dealing 
with   a    close-fitting    joint,    in    which    the    bone    is 


THE  ANKLE  2oZ 

fractured,  it  is  safest  for  the  present,  and  best  for 
the  future,  to  perform  excision  of  the  astragalus  at 
once.  This  operation  gives  good  drainage,  and  arrests 
the  sepsis  with  certainty.  Sometimes  it  has  to  be 
completed  by  incising  purulent  foci  in  the  tendon 
sheaths,  notably  in  those  of  the  peronei.  These 
incisions  are  called  for  if  the  temperature  remains 
high  after  resection  and  there  is  any  lateral  swelHng 
extending  up  the  leg.  At  times  it  is  necessary  to 
carry  the  incision  far  up  the  leg,  and  it  is  not  uncommon 
to  see  the  tendinous  and  aponeurotic  tissues  slough 
later.  Should  this  be  the  case,  in  order  to  accelerate 
recovery,  they  should  be  excised  instead  of  its  being 
left  to  nature  to  get  rid  of  them. 

It  is  often  possible  to  avoid  amputation,  if  the  neces- 
sary steps  are  taken  at  once.  If  the  gravity  of  the 
general  condition  or  the  extent  of  the  lesions  (suppura- 
tion of  the  whole  of  the  foot  and  leg)  makes  ampu- 
tation unavoidable,  disarticulation  of  the  foot  by 
Syme's  method  or  amputation  of  the  leg  should  be 
performed  ;  it  should  not  be  forgotten  that  a  plantar 
flap  can  be  used,  even  if  the  section  of  the  bone  has 
to  be  carried  high  up  (2  or  2i  inches  above  the  external 
malleolus). 

2.  A  Patient  arrives  with  Sinuses.— These  sup- 
purating sinuses  about  the  ankle  call  for  excision  of 
the  astragalus,  if  this  be  the  bone  that  is  the  seat  of 
mischief.  Time  must  not  be  lost  in  repeatedly  scrap- 
ing the  seat  of  the  osteitis.  In  a  bone  as  badly 
vascularised  as  this  and  composed  of  a  mass  of  can- 
cellous tissue,  osteitis  spreads  rapidly  and  involves 
the  whole  bone  ;  besides,  the  repair  of  a  cavity  scooped 
out  with  a  curette  cannot  be  effected  by  the  sinking 
in  of  its  walls.  A  cure  is  very  difficult  unless  the 
entire  bone  be  removed. 

If  there  are  sinuses  leading  to  the  os  calcis,  no 
decision  should  be  made  without  radiographs  ;  very 
often  indeed  osteitis  of  this  bone  reaches  the  joint 


254    THE  TREATMENT  OF  FEACTURES 

between  it  and  the  astragalus,  and  usually,  save  when 
it  occurs  in  the  posterior  or  plantar  margins,  it  becomes 
necessary,  from  what  I  have  seen,  to  begin  by  removing 
the  astragalus,  in  order  that  curettage  of  the  os  calcis 
may  have  good  results.  No  precise  rules  can  yet  be 
laid  down  for  this,  but  the  ideas  here  indicated  must 
not  be  lost  sight  of. 

3.  A  Patient  is  seen  with  a  vicious  Ankylosis, 
complete  or  otherwise,  fistulous  or  not,  the  foot  being 
fixed  in  equinus.  If  the  astragalus  is  affected,  it 
must  not  be  thought  that  the  tendo  Achillis  is  alone 
at  fault,  and  that  tenotomy  will  suffice.  Vicious 
ankylosis  of  the  ankle  ought  to  be  treated  by  simple 
excision  of  the  astragalus,  which  in  these  cases  gives 
perfect  orthopaedic  and  functional  results. 


CHAPTER    VIII 

WOUNDS    AND    FRACTURES     OP    THE    ANTERIOR 
TARSUS   AND  THE  FORE-PART   OP  THE  FOOT 

I.   Anatomical  Types  and  Clinical  Course 

All  the  wounds  of  the  anterior  tarsus  are  due  in  prac- 
tice to  splinters  of  grenade  or  shell.  Two  factors 
dominate  their  course  :  the  frequency  of  lesions  involv- 
ing many  bones,  and  accordingly  many  joints  ;  and 
the  constancy  of  the  speedy  incidence  of  sepsis  pro- 
ducing diffuse  suppuration  of  the  anterior  tarsus,  which 
is  too  often  treated  by  amputation,  when  early  opera- 
tions and  primary  resections  would  almost  always 
avoid  loss  of  the  foot. 

The  anatomical  types  are  very  diverse,  and  it  is 
dicffiult  to  classify  them  except  very  theoretically. 
We  may  find  : 

Fracture  of  one  bone  only  by  small  splinters  of  shell, 
with  the  missile  often  remaining  in  a  blind  wound. 

Oblique  punctured  fracture  of  many  bones,  the 
wound  extending  from  the  dorsum  to  the  sole,  and 
involving  either  the  outer  or  the  inner  arch  of  the 
tarsus. 

Punctured  transverse  fracture,  the  wound  going  from 
one  edge  of  the  foot  to  the  other. 

Complex  fractures  of  the  tarsus  and  metatarsus. 

Complex  fractures,  involving  the  posterior  tarsus. 

When  one  bone  only  is  affected,  a  localised  suppura- 
tive osteitis  may  occur,  and  after  the  formation  of  an 
abscess  a  sinus  may  form  without  the  inflammation 

255 


256     THE  TREATMENT  OF  FRACTURES 

spreading  to  the  neighbouring  bones,  joints,  or  the  soft 
parts  of  the  sole.  But  as  a  general  rule,  when  a  single 
bone  is  broken,  there  are  fissures  which  radiate  towards 
the  contiguous  bones  ;  when  several  bones  are  frac- 
tured, although  the  five  synovial  membranes  of  the 
fore-foot  may  be  normally  independent,  there  is  almost 
always  a  progressive  invasion  either  of  the  external 
group,  of  one  of  the  internal  groups,  or  of  the  whole 
of  the  anterior  tarsus.  So  that,  in  a  number  of  cases, 
the  anterior  tarsus  may  be  considered  as  one  bone, 
articulating  in  front  with  the  metatarsus,  and  behind 
with  the  astragalus. 

When  there  are  lesions  of  the  metatarsus,  the  situa- 
tion is  still  more  complex.  In  the  close-fitting  joints 
between  the  metatarsal  bones  infection  easily  spreads 
in  spite  of  any  drainage,  and  speedily  leads  to  septic 
symptoms  which  it  is  no  easy  matter  to  check,  except 
by  the  complete  removal  of  the  fore-foot,  or  even 
of  the  entire  foot. 

In  the  fractures  which  extend  to  the  posterior 
tarsus  the  position  is  quite  as  serious  ;  the  multi- 
plicity of  the  folds  of  synovial  membrane  make  it 
difficult  to  act  to  any  useful  purpose,  while  it  is  impos- 
sible to  drain  such  numerous  and  irregularly  situated 
cavities.  The  gravity  of  the  loial  phenomena  in  all 
these  lesions,  and  the  intensity  of  the  general  reaction, 
soon  demand  incisions  and  mutilations,  which  an  early 
operation  would  have  avoided. 

n.   Primary  Therapeutic  Indications 

1.  EsQuillectomy,  or  Resection  of  a  single  Bone. — In 

practice  esquillectomy  is  almost  always  ablation  of  one 
of  the  small  bones  of  the  anterior  tarsus.  It  is  indicated 
when  a  single  bone  is  fractured,  with  or  without  a 
missile  in  situ.  In  this  case  the  extraction  of  the 
projectile  and  the  early  scooping  out  of  the  cavity 
in  which  it  lies  give  excellent  results. 


ANTERIOR   TARSUS   AND  FOOT 


2o7 


The  scaphoid,  or  one  of  the  cuneiform  bones,  can  be 
removed  in  this  way,  and  early  resection  of  one  bone 
is  the  best  means  of  pre- 
venting the  spread  of  sepsis. 
In  the  case  of  the  scaphoid 
in  particular,  the  operation 
gives  perfect  results,  and 
resection  of  this  bone  alone 
ought  always  to  be  prac- 
tised when  possible.  But, 
if  the  lesion  is  more  wide- 
spread, if  many  bones  are 
involved,  or  many  synovial 
membranes  are  opened, 
there  must  be  no  hesitation 
in  completely  scraping  out 
the  bones  affected,  however 
atypical  the  operation  may 
be. 

It  is  important  that  this 
should  be  carried  out  every- 
where in  healthy  tissues  and 
with  free  incisions,  without 
which  atypical  operations 
become  dangerous.  There 
is,  however,  a  limit  to  this 
lateral  loss  of  tissue  ;  when 
more  than  a  third  of  the 
total  width  of  the  tarsus 
becomes  involved  in  these 
resections,  the  orthopaedic 
result  will  be  unsatisfactory. 
The  lateral  loss  of  tissue 
cannot  be  filled  up  with 
firm  new  growth.  The  cor- 
responding    m  e  t  a  t  a  r  s  a  1 

bones  are  gracluall}'  displaced,  at  first  backwards  and 
then  inclining  laterally ;    adjacent    metatarsal    bones 


Fig.  90. — Sub-periosteal  re- 
section of  the  ctiboicl  and  of 
the  third  cuneiform  with  sub- 
total resection  of  the  last  three 
metatarsals.  Orthoptedic  re- 
sult excellent .  The  officer  upon 
whom  this  operation  was  per- 
formed has  been  able  to  rejoin 
an  Alpine  battalion.  This 
radiograph  was  taken  on  the 
occasion  of  a  second  wound 
seven  months  after  the  first. 


258     THE   TREATMENT  OF  FRACTURES 

become  deflected  at  the  point  of  their  attachment  to 
the  tarsus. 

This  causes  secondary  varus  or  vulgus,  with  paiaful 
deformity  of  the  sound  side  of  the  foot  or  of  the  sole. 
That  is  why  Oilier  decided  on  orthopaedic  grounds  in 
favour  of  total  excision  of  the  anterior  tarsus,  when- 
ever it  is  impossible  to  leave  intact  rather  more  than 
one-half  of  the  width  of  the  tarsus. 

Good  results  may  nevertheless  be  got  by  getting  rid 
of  the  metatarsals  corresponding  to  the  damaged 
bones,  especially  if  they  are  injured.  The  functional 
result  of  this  excision  of  tarsus  and  metatarsus  is  good, 
but  its  appearance  is  deplorable. 

2.  Resection  o£  the  i^oiterior  Tarsus. — When  many 
bones  are  fractured,  especially  in  the  transverse  direc- 
tion, one  must  consider  the  necessity  of  an  extensive 
operation.  If  the  injuries  exceed  one-third  of  its  width, 
the  tarsus  should  be  treated  as  if  it  consisted  of  a 
single  bone  with  a  wide  periosteal  covering  reinforced 
by  numerous  and  firm  ligaments,  and  having  only  two 
articular  surfaces,  in  front,  the  cartilaginous  surface 
of  Lisfranc's  joint  (the  junction  of  the  tarsus  with  the 
metatarsus),  and  behind,  the  head  of  the  astragalus. 
The  entire  anterior  tarsus  should  then  be  removed 
by  sub-periosteal  resection.  If,  however,  the  scaphoid 
is  healthy,  it  should  be  left  in  place,  and  no  more  will 
be  done  than  ablation  of  the  three  cuneiforms  and  the 
cuboid  ;  a  partial  operation  which  is  followed  by  slight 
valgus,  but  which  allows  the  patient  to  walk  excellently 
and  is  quite  commendable. 

These  different  indications  may  appear  a  ittle 
theoretical,  and  certain  surgeons  think  they  need  not 
be  taken  into  account.  Satisfied  with  the  immediate 
result,  they  imagine  that  the  orthopaedic  result  is  one 
in  which  they  have  no  further  interest,  since  they 
suppose,  from  want  of  experience,  that  it  will  be  all 
they  desire.  The  observation  of  end-results  would 
quickly  undeceive  them.     But  it  is  not  necessary  to 


ANTERIOR  TARSUS  AND  FOOT        250 

be  eternally  repeating  the  experiences  of  the  past  ; 
the  end-results  of  these  operations  have  been  clearly 
ascertained  in  times  of  peace,  and  orthopaedic  princi- 
ples are  not  changed  by  the  nature  of  the  injuries. 

When  fractures  of  the  tarsus  are  complicated  with 
radiating  fissures  extending  to  the  metatarsus,  the 
opportunity  arises  to  combine  esquillectomy  of  the 
metatarsals  with  the  tarsal  operations.  If  a  partial 
operation  is  decided  upon,  the  metatarsal  bones 
should  not  be  interfered  with  more  than  is  strictly 
necessary.  If,  on  the  other  hand,  resection  of  th^ 
anterior  tarsus  is  deemed  advisable,  the  line  of  th« 
tarso-metatarsal  articulation  must  be  considered  as  ii 
the  metatarsus  were  a  single  bone,  and  a  flush  line  of 
section  made  with  the  saw. 

3.  Excision  of  the  Tarsus  (Total  or  Subtotal). — Wiien 
there  is  a  fracture  of  the  bones  of  the  anterior  tarsus, 
and  the  astragalus,  or  the  os  calcis,  or  both  of  them, 
are  involved,  early  intervention  is  more  pressing  than 
ever.  A  smash  of  the  tarsus  is  indeed  perfectly 
amenable  to  a  conservative  operation,  but  it  must  be 
primary,  and  the  surgeon  must  not  wait  for  the 
occurrence  of  diffuse  suppuration  before  acting.  There 
will  be  no  question  of  absolutely  typical  operations, 
but  one  must  be  directed  by  the  principles  governing 
a  typical  resection,  and  must  recogoise  that  in  total 
excision  of  the  tarsus  one  has  a  marvellous  means  of 
avoiding  amputation.  In  this  proceeding,  the  frac- 
tured tarsus  is  to  be  considered  as  formed  of  one  single 
bone,  reinforced  by  firm  ligaments,  and  as  having 
only  two  articulations,  a  tibio- tarsal  and  a  tarso- 
metatarsal. When  this  tarsal  mass  has  been  removed 
by  the  sub-periosteal  method,  there  remains  what 
Oilier  calls  a  "  suro-metatarsal  "  cuff,  which  unites 
the  bones  of  the  leg  with  the  posterior  extremities  of 
the  metatarsals.  Behind,  the  insertion  of  the  tendo 
Achillis  strengthens  it ;  below,  there  are  the  liga- 
ments between  the  cuboid  and  os  calcis  ;   at  the  sides, 


260    THE   TREATMENT  OF  FRACTURES 

the  ligaments  between  the  tarsus  and  the  tibia  and 
fibula.  This  sheath  is  very  resistent,  and  when,  thanks 
to  the  periosteum,  new  osseous  plaques  are  formed  in 
it,  it  is  able  to  recover  sufficient  strength  to  support 
the  weight  of  the  body  and  to  connect  the  metatarsus 
closely  with  the  bones  of  the  leg. 

There  is  a  further  reason  for  this  operation  after 
destruction  of  the  tarsus  by  gun-shot  wounds.  In 
these  cases  certain  healthy  tissues  can  be  preserved, 
such  as  the  posterior  and  inferior  part  of  the  os  calcis, 
and  in  these  circumstances  the  orthopaedic  results  will 
be  even  better.  Atypical  clearing  out  of  the  space 
between  the  tibia  and  the  metatarsus  ought  to  be  prac- 
tised whenever  the  condition  of  the  soft  parts  allows, 
and  if,  while  preserving  the  periosteum  and  the  healthy 
bone,  one  is  careful  to  leave  no  irregular  surfaces,  with 
diverticula  which  it  is  difficult  to  drain,  many  ampu- 
tations will  be  avoided. 

4.  Amputation. — Primary  amputation  is  rendered 
necessary,  rather  by  the  extent  of  the  injury  to  the 
soft  parts,  than  by  the  damage  to  the  bone  strictly 
speaking ;  in  excision  of  the  tarsus,  typical  or  atypical, 
one  can  always  deal  with  the  tarsus,  however  exten- 
sively destroyed.  But  if  the  skin  is  torn  and  the 
tendons  are  hopelessly  damaged,  this  fundamental 
idea  i>hould  be  our  guide  :  when  dealing  with  the 
foot,  it  is  necessary  before  all  things  to  try  to  obtain 
a  solid  and  painless  support  for  walking  and  for 
standing. 

Consequently,  when  the  destruction  of  the  soft  parts 
is  too  extensive  to  allow  one  to  hope  for  a  cicatrix 
capable  of  bearing  pressure,  amputation  should  be 
performed  at  once,  but  amputation  of  the  leg  must  be 
avoided  if  possible.  If  the  fore-foot  and  the  anterior 
tarsus  are  crushed,  Chopart's  disarticulation  will  not 
oenerally  be  adopted,  or  indeed  any  other  measure  of 
this  kind ;  the  necessary  material  for  the  typical 
flaps  will  always  be  wanting.     It  will  be  better  co  innit 


ANTERIOM   TARSUS   AND  FOOT  261 

oneself  to  a  level  section,  and  to  try  later  to  form  a 
permanent  flap.  The  skin  is  divided  at  the  level  of 
the  contused  tissues  either  on  the  dorsum  or  the  sole 
of  the  foot,  keeping  as  much  of  the  tissues  of  the 
foot  as  possible  without  disarticulating,  but  proceeding, 
so  to  speak,  as  in  esquillectomy.  At  a  lacer  date, 
sometimes  quite  soon  if  sepsis  does  not  supervene, 
secondary  sutures  can  be  put  in  and  a  suital>).e  stump 
formed  :  in  a  case  of  this  kind  with  multiple  fractures, 
I  was  able  subsequently  to  cover  over  the  scaphoid 
and  the  cuboid,  when  a  typical  primary  operation 
would  certainly  have  driven  me  to  disarticulation  at  the 
tibio-tarsal  joint. 

Must  Chopart's  operation  be  condemned  when  there 
is  sufficient  material  ?  One  always  blames  that 
operation  for  the  "  tilted "  fully  extended  stump, 
which  makes  the  patient  walk  upon  the  tuberosity 
of  the  OS  calcis,  or  even  on  the  head  of  the' astragalus  ; 
and  Tuffier  does  not  advise  the  operation,  which  has 
often  given,  he  says,  stumps  that  cannot  be  used.  I 
have  had  no  personal  experience  of  it,  never  having 
performed  medio- tarsal  disarticulation,  but  I  have 
seen  some  patients  upon  whom  it  had  been  done  by 
Berard,  w^ho  walked  very  well.  In  short,  when  there 
is  enough  skin,  Chopart's  operation  is  legitimate,  but 
only  in  very  favourable  cases.  That  is  as  good  as 
saying  that  the  indications  for  its  adoption  will  be  few. 

If  the  lesions  of  the  soft  parts  art^  more  extensive, 
the  surgeon  will  disarticulate  at  the  ^tibio-tarsal  joint, 
with  or  without  section  of  the  os  calcis. 

Three  types  of  operation  are  possible  : 

Syme's  disarticulation  with  sub-perici steal  decortica- 
tion of  the  OS  calcis  after  the  method  of  Oilier. 

Pirogoff's  tibio-tarsal  disarticulation  with  oblique 
section  of  the  os  calcis. 

Guyon's  supra -malleolar  amputation. 

To  sum  up  :  curetting,  or  resection  of  a  single  bone, 
in  cases  of  limited  injury  ;    partial  resection,  if  the 


263     THE   TREATMENT  OF   FRACTURES 

damage  does  not  extend  over  more  than  one-third 
of  the  width  of  the  fore- foot ;  anterior  tarsectomy, 
if  the  lesions  are  more  extensive  ;  atypical  total 
tarsectomy,  if  the  injuries  affect  the  posterior  tarsus  ; 
amputation  through  the  tarsus  or  os  calcis,  or  above 
the  malleoU,  if  the  soft  parts  are  gone,  and  if  the  foot 
is  destroyed. 


m.   Operative  Technique 

All  the  operations  on  the  anterior  tarsus  ought  to  be 
done  with  the  rugine,  strictly  sub-periostea lly,  without 
dividing  any  tendons  in  the  incisions. 

1.    ESQUILLECTOMY,     OR     RESECTION     OF     \     .SINGLE 

Bone. — ^An  incision  is  made  over  the  orifice  of  entry 
of  the  missile,  and  when  the  per- 
forated bone  is  reached,  it  is  cleared 
out  with  a  curette.  If  the  injury  is 
shght,  the  procedure  will  cease  when 
the  missile  has  been  removed ;  but 
if.  the  clearing-out  process  leaves 
any  loose  cartilaginous  fragments. 
it  is  better  to  remove  the  bone 
entirely. 

2.  Resection  of  the  Anterior 
Tarsus. — ^The  regular  ablation  of 
the  bones  of  the  tarsus  is  done  ac- 
cording to  the  indications  of  Oilier, 
by  means  of  three  or  four  incisions 
parallel  with  the  long  axis  of  the 
foot,  so  as  to  sacrifice  neither  ten- 
dons, muscles,  vessels,  nor  nei-ve-s. 
One  commences  on  the  side  of  the 
foot  at  which  the  injuries  arc  most 
extensive,  for  example  the  internal  edge. 

The  first  indsion  will  be  at  this  level.  It  will  com- 
mence a  Httle  behind  the  tubercle  of  the  scaphoid  and 
will  extend  do^vn  just  beyond  the  joint  between  the 


Fig.  91.  —  The 
different  incisions 
for  use  in  anterior 
resection  of  the 
tarsus. 


ANTERIOR   TARSUS  AND  FOOT        263 

first  metatarsal  and  the  internal  cuneiform.  The 
periosteo-capsular  sheath  will  be  incised  along  the 
lower  edge  of  the  bones,  whatever  injury  they  may 
have  sustained.  A  point  at  which  the  periosteum  and 
the  ligaments  are  sound  is  chosen  as  a  starting-point 
for  the  detachment,  and  this  is  done  as  completely 
as  possible,  passing  below  the  tendon  of  the  tibiahs 
posticus,  and  following  along  the  abductor  hallucis. 

The  second  incision  is  made  along  the  outer  edge 
of  the  extensor  proprius  hallucis,  in  order  to  avoid  the 
dorsaUs  pedis  artery  which  is  shghtly  to  its  outer  side. 
The  periosteo-capsular  sheath  is  opened  along  the 
outer  edge  of  the  internal  cuneiform. 

The  third  incision  corresponds  with  the  joint  between 
the  cuboid  and  the  external  cuneiform,  and  passes 
between  the  fourth  and  fifth  extensor  tendons. 

The  fourth  incision  lies  over  the  outer  border  of  the 
cuboid.  It  follows  the  upper  edge  of  the  peroneus 
brevis  tendon. 

This  is  all  no  doubt  very  diagrammatic,  and  often 
the  extent  of  the  lesions  will  not  permit  so  rigorous  a 
technique.  But  the  spirit  rather  than  the  letter  should 
be  followed  ;  the  object  is  not  to  divide  tendons,  but 
still  to  have  enough  room  to  remove  the  bones  easily. 
No  fractured  bone  should  be  forcibly  torn  out  ;  it  is 
no  advantage  to  sever  with  the  bistoury  the  ligaments 
which  fix  it  in  place.  Ablation  should  be  effected  with 
the  sharp  rugine  and  the  hgaments  should  be  preserved 
as  far  as  possible. 

When  all  the  bones  are  removed,  the  Hne  of  the 
articular  surface  of  the  metatarsus  is  a  somewhat 
irregular  one  ;  Ukewise,  posteriorly,  where  the  head  of 
the  astragalus  stands  out^  as  does  the  second  meta- 
tarsal in  the  joint  (i.e.  tarso-metatarsal)  of  Lisfranc. 
It  is  unnecessary  to  make  these  surfaces  flush  ;  the 
periosteum,  which  has  been  preserved,  levels  all  in- 
equalities and  assures  juxtaposition  of  the  astragalus 
and  metatarsus. 


264    THE   TREATMENT  OF  FRACTURES 

After  the  operation  all  the  incisions  are  left  open, 
and  a  gauze  drain  is  placed  transversely  at  the  level  of 
the  anterior  astragalo-calcanean  joint. 

3,  Total  Tarsectomy. — ^This  operation, if  performed 
methodically,  allows  feet  to  be  preserved  which  have 
had  their  bony  tissues  completely  destroyed.  The 
operation  sacrifices  the  bones  of  the  anterior  tarsus 
and  the  astragalus,  which  ought  always  to  be  com- 
pletely removed,  but  it  rigidly  preserves  the  inferior 
surface  and  the  tuberosities  of  the  os  calcis.  It  can 
easil}^  be  done  by  means  of  the  incisions  for  excision 
of  the  astragalus  combined  with  the  dorsal  incisions 
described  above  for  excision  of  the  anterior  tarsus. 
The  entire  operation  should  be  rigidly  sub -periosteal, 
so  as  to  presei-ve  as  much  tissue  as  possible  for 
padding  to  fill  up  the  immense  cavity  left  by  the 
operation. 

4.  Amputation. — The  discussion  of  the  various  types 
of  amputation  already  given  (page  561 )  furnishes 
technical  indications  for  the  choice  of  any  particular 
-method  according  to  the  case  under  observation.  As 
to  actual  points  of  technique,  we  need  give  only  the 
following  details  : 

The  transverse  incision  of  Syme  is  excellent,  when- 
ever it  is  possible.  If  an  osteoplastic  amputation  is 
done,  it  is  not  necessary  to  follow  the  classical  rules. 
The  exact  extent  of  the  bone-section  will  vary  with 
the  dimensions  of  the  flap  available.  If  ample  soft 
parts  are  at  hand,  a  typical  Pirogoff  may  be  done  or 
the  cut  surface  of  the  os  calcis  may  be  trimmed 
so  as  to  adapt  it  to  the  tibio-fibular  arch  which  is  not 
then  resected  (Quenu),  especially  if  it  is  essential  to 
gain  time. 

If  it  is  necessar}^  to  remove  the  os  calcis,  decortica- 
tion of  that  bone  should  be  done  with  the  rugine, 
according  to  the  practice  of  OlUer.  The  advantage 
of  this  is  that  the  flap  is  thicker,  better  nourished,  and 
better  padded,  and  finally  becomes  furnished  with  an 


ANTERIOR   TARSUS  AND   FOOT 


26- 


osteo-fibrous  core.  It  is  also  easier  to  do,  and  the 
end-result  is  far  preferable. 

The  heel  flap,  lined  with  periosteum,  can  be  used 
even  when  as  much  as  four  inches  of  the  bones  ot 
the  leg  mnst  be  sacrificed.     The  stump  left  is  no  doubt 
irregular   and    awkward  ; 
but   it   gradually    adapts 
itself,  and  in  the  end  the 
functional    result    is    ex- 
cellent. 

After  disarticulation  of 
the  foot,  it  is  unnecessary 
to  resect  the  tibial  surface 
and  remove  the  malleoli. 
It  is  customary  to  do  this 
in  operative  surgery  on 
the  cadaver,  but  it  pre- 
sents no  practical  utility. 
I  have  seen  a  patient 
eight  months  after  a  dis- 
articulation in  which  I 
had  left  the  malleoli  ;  he 
walked  very  well,  without 
pain,  and  with  a  boot  im- 
provised by  himself. 

After  typical  tibio- 
tarsal  disarticulation,  it 
is  found  advisable  as  a 
preventive  measure  to 
divide  the  tendo  Achillis. 
Since  primary  suture  of 
the  anterior  and  posterior 
tendons  and  of  the  skin 
flaps    cannot    and    ought 

not  to  be  done  in  these  cases,  the  stump  would  be 
likely  to  retract  under  the  pull  of  the  soleus  and 
gastrocnemius.  Open  section  of  the  tendo  Achillis 
will  prevent  this  ;  the  tenotomy  wound  can  be  used 


Fig,  92. — Disarticulation  of 
the  foot  by  Syme's  operation, 
without  cutting  through  the 
malleoli.  Walking  is  easy  and 
painless  with  an  improvised  ap- 
paratus. The  change  effected  in 
eight  months  in  the  tibio-tarsal 
articular  surface  is  noticeable 


266     THE   TREATMENT  OF  FRACTURES 

for  drainage,  and  has  the  advantage  that  it  is  at  the 
lowest  point. 

After  the  operation,  a  gauze  drain  is  inserted  after 
the  flap  has  been  fastened  in  place  by  one  or  two 
anterior  sutures  ;  a  few  other  temporary  sutures  are 
inserted  at  the  angles.  On  each  side  a  drain  of  gauze 
is  slipped  into  the  cavity  of  the  heel,  which  always 
oozes.  These  drains  are  removed  at  the  first  dressing, 
and  if  all  goes  well,  the  temporarj'^  stitches  are  tied. 

IV.   Post-Operative  Treatment 

This  is  practically  identical  with  that  for  operations 
for  injuries  of  the  ankle. 

1.  Apteb  Partial  Eesection  op  the  Anterior 
Tarsus  — The  foot  is  rigidly  immobiHsed  in  a  plaster 
casing  which  supports  the  toes  and  extends  above  the 
knee.  The  dressing  must  be  done  at  long  intervals, 
so  as  to  secure  immobiUsation  for  a  very  long  time, 
even  after  cicatrisation  ;  thisis  necessary  to  overcome 
the  traction  of  the  scar-tissue,  which  tends  to  cause 
deviation  of  the  front  of  the  foot.  One  must  bear  in 
mind  the  frequency  of  the  various  deformities  which 
follow  this  retraction  and  the  dislocation  of  the  foot 
which  may  result  from  the  changes  which  the  normal 
supporting  surfaces  of  the  sole  have  undergone.  Later 
on,  if  it  is  not  guarded  xigainst,  there  will  be  a  deviation 
of  the  bones  and  projections  which  will  compress  the 
nerves  in  the  sole  and  cause  painful  pressure.  Before 
the  war  late  amputations  had  to  be  done,  because  of 
the  painful  and  troublesome  deformity.  The  process 
of  periosteal  repair  must  therefore  be  aided  by  main- 
taining the  foot  for  a  long  time  in  a  normal  position. 
Walking  will  only  be  allowed  some  considerable  time 
after  cicatrisation  has  occurred,  and  then  only  with 
an  orthopaedic  boot.  It  might  be  worth  trying  to 
remedy  the  defects  remaining  by  the  help  of  grafts  of 
cartilage. 


ANTERIOR  TARSUS  AND  FOOT        267 

2.  After  Total  Anterior  Tarsectomy. — After 
drainage  has  been  established  as  has  been  described 
above,  and  the  incisions  have  been  plugged  with  gauze, 
the  foot  is  immobilised  in  the  usual  posterior  plaster 
casing.  The  first  dressing  is  delayed  as  long  as  possible, 
at  least  eight  to  ten  days,  if  there  is  no  rise  of  tem- 
perature. It  will  then  be  found  that  the  soft  parts 
have  come  together  to  a  considerable  degree,  giving 
to  the  foot  a  peculiar  shape  so  characteristic  that  it 
cannot  be  mistaken  for  any  other  condition  :  the 
plantar  arch  has  become  convex  ;  it  is  what  OUier 
has  called  the  "  dkate-shaped  "  foot.  There  is  no 
need  to  be  anxious.  This  deformity  is  due  to  the 
action  of  the  muscles  of  the  leg,  the  os  calcis  being 
tilted  by  the  tendo  Achilhs,  whilst  the  anterior 
segment  of  the  foot  tilts  in  the  opposite  direction  under 
the  action  of  the  extensors  of  the  toes.  Little  by  httle 
the  projection  decreases,  as  cicatrisation  takes  place, 
and  the  final  result  is  good.  Walking  ought  not  to  be 
permitted  before  three  or  four  months. 

3.  After  Tarsectomy,  Total  or  Complex. — ^The 
foot  is  immobiUsed,  as  usual,  in  the  posterior  plaster 
casing  extending  up  above  the  knee.  This  is  removed 
at  each  dressing,  an  assistant  holding  the  forefoot  with 
one  hand,  and  the  leg  with  the  other.  After  some 
time  the  first  plaster  casing  will  have  become  too 
large,  and  a  properly  fitting  one  is  substituted. 

The  course  of  the  case  is  generally  uneventful,  and 
complete  recovery  requires  from  five  to  six  months. 
Walking  mth  the  weight  borne  direct  upon  the  sole 
is  not  allowed  before  that  time. 

4.  After  Amputation  or  Disarticulation  of  the 
Foot. — ^No  special  care  is  necessary,  except  after 
Syme's  operation  ;  in  the  latter,  if  the  temperature 
is  raised,  or  there  are  symptoms  of  local  infection, 
retention  of  the  discharges  in  the  hollow  of  the  heel 
may  be  suspected.  The  best  way  of  checking  it  is  to 
remove  the  stitches  and  let  the  flap  han^  widely  open. 


268    THE   TREATMENT  OF  FRACTURES 

Aften^'ards  it  mil  be  supported  and  held  in  place 
by  bandages,  which  generally  suffice  to  secure  satis- 
factory healing  with  the  flap  in  the  right  position. 


V.   Evacuation  of  Patients  with  Anterior  Tarsal  Wounds 

These  patients  can  be  sent  away  shortly  after  the 
primary  operation  has  been  performed.  After  resec- 
tion of  one  bone,  or  after  extraction  of  a  missile,  a 
patient  can  be  evacuated  at  the  end  of  forty-eight 
hours.  An  anterior  tarsectomy  ought  to  be  kept 
for  from  six  to  eight  days,  a  total  tarsectomy  from 
twelve  to  fifteen  days.  In  case  of  necessity,  all  of 
these  could  be  evacuated  early,  ihuch  more  easily  than 
if  they  had  not  been  operated  upon. 

The  journey  should  not  exceed  twenty-four  hours 
by  rail. 

The  ideal  apparatus  for  travel  is  the  posterior  plaster 
casing. 


VI.   Treatment  of  Patients  seen  late  or  after  Evacuation 
1.  A  Patient  is  seen  w^ith  active  Sepsis.^ — If  he 
has  been  insufficiently  operated  upon,  or  not  incised, 
three  different  conditions  may  be  present  : 

id)  If  it  is  a  blind  wound,  caused  by  a  shell-splinter 
which  has  not  been  removed  and  has  caused  great 
damage,  there  is  limited  sepsis  of  the  foot  with  more  or 
less  extensive  pockets  of  pus.  The  necessary  incisions 
will  be  made,  so  as  to  check  the  acute  symptoms  and 
remove  the  missile,  the  decision  as  to  which  is  the  best 
operation  for  the  bone  and  joint,  whether  ablation 
of  the  bone,  scraping  out,  or  typical  resection,  being 
reserved  for  a  later  date  ;  this  will  be  made  according 
to  the  indications  from  the  orthopaedic  point  of  view, 
which  are  explained  above. 

(b)  If  it  is  a  ivound  penetrating  the   hone,  the  skin 


ANTERIOR   TARSUS   AND  FOOT        8  69 

wounds  being  ragged  but  not  extensive,  the  case  is 
one  of  suppurative  osteo-arthritis,  which  is  manifested 
by  severe  constitutional  disturbance,  high  temperature, 
and  a  serious  local  condition.  The  whole  of  the  dorsum 
of  the  foot  as  far  as  the  tibio-tarsal  joint  is  swollen  and 
oedema tous,  with  livid  patches.  From  the  orifices  of 
entry  and  exit  exudes  a  turbid  discharge.  Sometimes 
the  lesion  is  indolent,  and  arthritis  develops  without 


Fig.  93. — Sub-total  resection  of  the  tarsus  for  suppurative 
arthritis  of  all  the  joints.  The  patient  had  undergone  amputa- 
tion of  an  arm  at  the  front  for  fracture  ;  he  had  many  wounds  :  one 
wound  through  the  tarsus  was  not  attended  to  on  arrival  at  my 
station.  The  patient,  jaundiced,  weak,  and  feverish,  was  in  a  bad 
way.  A  month  after  resection  of  the  tarsus,  which  was  performed 
thirty  days  after  the  injury,  the  general  condition  was  much  im 
proved  and  the  foot  on  the  way  to  cicatrisation.  Radiograph  taken 
eight  days  after  operation. 

much  reaction,  but  the  condition  is  quite  as  severe. 
Still,  there  is  no  reason  to  consider  that  amputation  is 
inevitable. 

After  radiography,  resection  should  be  at  once 
resorted  to  ;  it  should  be  either  total  anterior  tarsec- 
tomy,  or  a  complex  tarsectomy,  sacrificing  as  much 
bone  as  is  necessary  to  obtain  a  cavity  with  walls  which 


270    THE   TREATMENT  OF  FRACTURES 


are  smooth,  clean,  and  free  from  diverticula.  This 
will  often  lead  to  removal  of  the  astragalus  as  well 
as  the  whole  of  the  anterior  tarsus,  or  even  most 
of  the  OS  calcis.  Any  cavity  and  all  pockets  of  pus 
must  be  opened  freely.  In  one  case  of  this  kind  I 
only  left  the  os  calcis  and  four  of  the  metatarsals, 

and    even     three     of 
Mi^..M^  ^      these    were    sawn 

through  just  beyond 
their  bases.  It  might 
perhaps  be  objected 
that  disarticulation  of 
the  foot  wouM  have 
been  better,  but  such 
is  not  the  case :  the 
immediate  and  future 
results  of  these  opera- 
tions are  excellent, 
when  the  operation 
has  been  correctly 
performed,  and  when 
the  post  -  operative 
treatment  is  suitably 
attended  to. 

If  the  foot  is  no 
more  than  a  bag  of 
pus,  if  the  tendons  are 
extensively  torn,  and  if  the  constitutional  condition 
is  serious,  without  question  the  decision  will  be  in 
favour  of  amputation.  When  the  injury  involves  the 
tarsus  and  metatarsus,  amputation  will  be  done  by  a 
level  section,  according  to  Quenu's  advice,  through  the 
middle  of  the  tarsus,  at  the  level  of  the  seat  of  injury, 
without  troubling  about  the  lines  of  the  joints  unless 
the  extent  of  the  plantar  skin  allows  of  a  typical  dis- 
articulation. In  any  case  the  wound  will  be  dressed 
wide  open  and  the  plastic  covering-in  will  only  be  done 
later. 


Fig.  94. — Amputation  straight 
through  the  tarsus.  Secondary  skin 
sutures.  Walking  with  a  suitable 
boot  is  easy. 


ANTERIOR  TARSUS  AND  FOOT         271 

When,  on  the  contrary,  a  wound  of  the  anterior 
tarsus  is  in  question,  the  best  operation  is  disarticu- 
lation of  the  foot,  with  section  of  the  os  calcis,  or  the 
Syme-Ollier  operation. 

If  the  posterior  tarsus  is  affected,  the  foot  should  be 
disarticulated,  or  a  supra-malleolar  amputation  done 
with  a  heel  flap,  or  Guyon's  posterior  flap. 

The  wound  is  left  largely  open ;  the  flaps  will  only 
be  kept  together  by  one  or  two  sutures  for  the  time 
being. 

If  the  wound  is  on  the  surface,  and  if  there  has 
been  much  laceration  of  the  skin,  with  loss  of  muscles 
and  tendons  and  absence  of  the  soft  parts,  the  septic 
condition  is  less  grave,  but  the  decision  as  to  the 
operation  most  suitable  is  perhaps  still  more  difficult. 
When  a  certain  amount  of  skin  has  been  lost,  resection 
is  still  possible  ;  in  other  cases,  amputation  becomes 
necessary.  It  is  impossible  to  lay  down  fixed  rules  ; 
it  is  a  question  of  degree,  and  a  matter  for  surgical 
experience.  As  a  general  rule,  it  is  best  not  to  sacri- 
fice anything  at  first. 

2.  A  Patient  is  seen  with  Sinuses. — ^Unless  the 
injury  is  very  limited,  as  demonstrated  by  radiography, 
a  minor  operation  is  not  much  use  ;  resection  is  often 
necessary,  and  it  will  be  better  to  do  it  early,  accord- 
ing to  the  severity  of  the  lesions.  In  certain  cases, 
disarticulation  at  the  tibio-tarsal  joint  or  amputation 
through  the  os  calcis  is  called  for. 

3.  A  Patient  is  seen  with  a  Deformity  of  the 

FOOT     WHICH     prevents       HIM     FROM       WALKING. — A 

typical  resection  may  be  tried,  in  default  of  which,  the 
only  resort  will  be  amputation  (Syme's  or  Pirogoff's). 


CHAPTER    IX 
MULTIPLE  JOINT  WOUNDS 


One  frequently  observes  multiple 
articular  wounds  caused  either  by 
machine-gun  wounds  or  by  shell 
splinters.  Every  possible  com- 
bination is  seen,  of  which  the  most 
frequent  appear  to  be  wounds  of 
the  shoulder  and  elbow 
of  the  same  arm,  and 
those  of  both  knees. 
When  this  is  the  case,  the 
customary  rule  of  syste- 
matic operative  prophy- 
laxis should  be  more 
absolute  and  imperative 
than  ever  ;  any  wound 
near  a  joint,  however 
small  it  mav   be.  should 


\^ 


not  be  neglected. 
some  other 
serious  accom- 
panying wound 
appears  to  de- 
mand exclusive 
attention.  This 
is  the  only  way 
to  avoid  cruel 
disappoint- 
ments. 

An  explora- 
tory incision 
should  be  made 
for  each  joint 
injured,  and  the 
operation     se- 


even    it    M^  Fk;.  Uo. — Double  resec- 

tion performed  on  the 
same  limb  in  the  en- 
deavour to  avoid  disar- 
ticulation at  the  shoulder. 
The  patient  was  seen  on 
the  third  day  ^vith  septic 
symptoms  ;  the  upper 
third  of  the  humerus  was 
comminuted  and  the  up- 
per extremity  of  the  ulna 
and  the  head  of  the  radius 
were  fractured.  Resec- 
tion of  the  upper  extremi- 
ties of  the  radius  and  vilna 
and  esciuillectomy  of  the 
humerus  were  performed 
at  the  first  sitting,  and 
three  days  later  the  head 
of  the  humerus  was  dis- 
articulated.      The    result 

at  the  end  of  six  months  was  as  indicated 

in  figs.  06  and  97. 
272 


MULTIPLE   JOINT    WOUNDS 


273 


lected  will  be  that  which  is  demanded  by  what  is 
found :  exploratory  arthrotomy  with  simple  extraction 
of  the  missile  if  there  is  no  fracture,  or  with  limited 
sub-periosteal  esquillectomy  if  a  slight  parietal  fracture 
is  encountered  ;  resection  in  any  other  case,  in  short, 
each  articular  lesion  will  be  treated  as  if  it  existed 
alone. 

In  cases  of  doubt  the  most  radical  means  should  be 


Fig.  9G. — Notwithstanding  the  amount  of  the  humerus  which 
M'as  removed,  movements  of  the  arm  and  forearm  were  possible 
to  the  extent  shown  in  the  above  photographs.  The  play  of  the 
hand  is  complete,  except  for  a  slight  loss  of  power  in  the  ulna 
muscles  due  to  a  wound  of  the  forearm  ;  the  play  of  the  fingers  is 
normal. 

cho.sen.  For  example,  resection  should  be  done  in 
preference  to  esquillectomy,  or  amputation  in  prefer- 
ence to  resection,  if  either  of  the  latter  appears  at  all 
hazardous. 

Sometimes  in  this  way  one  will  be  led  to  do  two 
resections  upon  the  same  limb  ;  Gayet  has  reported 
a  case  of  resection  of  the  knee  and  of  the  astragalus 


274     THE  TREATMENT  OF  FRACTURES 

of  the  same  side.  I  myself  have  done,  on  the  same 
limb,  a  very  extensive  double  resection  of  the  shoulder 
and  a  resection  limited  to  the  extremities  of  the  fore- 
arm at  the  elbow,  with  an  excellent  result.  The 
wounded  man,  who  has  lost  more  than  one-third  of 
the  humerus,  easily  contracts  his  shoulder  muscles 
in  order  to  draw  up  the  remainder  of  his  humerus. 


Fig.  97. — Drapier's  apparatus  taking  the  place  of  the  humerus 
which  has  been  removed  and  permitting  very  satisfactory  move- 
nients  of  the  upper  limb. 


and  to  give  a  solid  fulcrum  to  the  flexors  of  his  forearm. 
This  done,  he  is  able,  without  any  appliance,  to  bring 
his  forearm,  with  some  energy,  to  more  than  a  right 
angle.  With  an  apparatus,  the  function  of  the  limb 
is  very  satisfactory,  and  the  hand  very  useful.  Double 
resection  has  certainly  avoided  amputation  in  this 
case,  which  was  operated  upon  when  sepsis  was  in  full 


MULTIPLE  JOINT    WOUNDS  275 

swing  and  the  general  and  local  phenomena  were 
grave.  It  may  be  added  that  he  had  several  other 
wounds  of  the  skull  and  the  face. 

In  another  patient  I  did  an  arthrotomy  for  extrac- 
tion at  the  knee  and  a  resection  of  the  shoulder  and 
another  of  the  elbow,  with  good  functional  results. 

It  is  seen,  then,  that  even  with  very  extensive  multiple 
injuries,  conservative  surgery  has  its  indications  and 
its  efficacy,  but  it  is  of  importance  to  act  more  rapidly 
than  ever,  and  to  use  complete  operative  prophylaxis 
against  infection  for  even  the  slightest  wound. 

To  sum  up :  in  the  most  complex  cases,  it  is  at  once 
necessary  and  sufficient  to  apply  this  fundamental 
precept  of  military  surgery,  which  is  at  the  same  time 
the  cardinal  principle  of  conservative  surgery  as 
applied  to  joints. 


THE 

TREATMENT  OF  FRACTURES 

PAKT.    II 

FRACTURES  OF  THE  SHAFT 

CHAPTER   X 

A  GENERAL  STUDY  OF  SHAFT  FRACTURES 

Apart  from  the  formidable  crushing  of  limbs,  with 
complete  shattering  of  bone  and  extensive  destruction 
of  muscles,  blood-vessels,  and  nerves,  such  injuries,  in 
fact,  as  can  scarcely  be  studied  as  fractures,  there  are 
in  war  surgery,  from  the  point  of  view  of  treatment,  only 
two  great  types  of  shaft  fracture  :  those  produced  by 
long-range  bullets,  which  strike  the  limb  in  the  ordinary 
way,  point  first,  perforating  the  soft  parts  and  only 
producing  very  small  wounds  as  they  pierce  the  skin, 
and  those  caused,  by  other  projectiles,  short-range  bullets, 
or  the  explosion  of  shells,  bombs,  mines  and  torpedoes,  etc. 

The  former  progress  like  simple  fractures,  do  not 
suppurate,  and  are  not  liable  to  serious  infection  : 
they  get  well  easily  and  quickly.  These  were  once 
regarded  as  the  ordinary  type  of  war-fracture. 

The  latter  are  always  infected  at  the  outset,  and 
the  development  of  the  infection,   though  always  a 

277 


278  TREATMENT   OF   FRACTURES 

matter  for  concern,    varies    in    the    severity    of    its 
results.* 

The  former  are  becoming  more  and  more  rare  in 
modern  warfare  even  during  fighting  in  the  open.  No 
operation,  or  at  least  no  early  operation,  should  be 
performed ;  absolute  immobility  and  continuous  exten- 
sion suffice  for  recovery.  This  type  will  receive  little 
discussion  in  this  book,  which  concerns  itself  princi- 
pally with  surgery  at  the  front. 

The  latter  form  an  enormous  proportion  of  our 
cases  nowadays ;  the  operation  of  sub-periosteal 
esquillectomy  f  should  be  performed  systematically  as 
early  as  possible  ;  in  this  way  all  complications  that 
threaten  will  be  avoided,  and  further  progress  will  be 
aseptic  and  end  in  good  union  and  healing. 

It  is  with  this  .type  that  I  am  henceforth  con- 
cerned. 

I  must  first,  however,  enumerate  the  points  which 
distinguish  the  two  types.  Asa  matter  of  fact,  only 
the  nature  of  the  wound  of  entry  need  be  noted  ;  there 
is  no  other  means  of  forming  a  conclusion,  and  this 
one  is  satisfactory  in  itself.  The  skin  wounds  are  very 
small  and  insignificant,  suggesting,  at  the  points  both 
of  entry  and  of  exit,  the  appearance  of  a  trochar  punc- 
ture :  they  are  "  punctiform  "  wounds,  to  use  the 
convenient  term  which  Ferraton  has  .brought  into 
general  use.  The  wound  of  exit  is  scarcely  larger 
than  the  wound  of  entry  :  if  it  is  larger  than  a  cherry 
stone  there  is  some  danger  of  a  slight  infection,  cer- 
tainly not  always,  but  frequently  to  a  sufficient  degree 
to  prevent  closure  for  some  time ;    if  it  should  be  as 

*  Womids  by  shrapnel  btillets  are  decidedly  less  serious  than 
those  caused  by  shell-fragments.  They  are,  in  a  sense,  intermediate 
between  the  two  groups  described  above.  But  though  their  sup- 
puration is  sometimes  benign,  it  can  be  and  frequently  is  very 
serious ;  they  should  therefore  undoubtedly  be  studied  in  the 
category  of  fractures  by  shell  explosion. 

t  This  term  will  be  used  throughout,  as  in  Part  I,  to  denote  the 
removal  of  bony  fragments  and  splinters  afteflp  separation  from 
their  periosteal  covering. — Ed. 


GENERAL  STUDY  OF  SHAFT  FRACTURES     279 

large  as  a  shilling,  infection  is,   if  not  invariable,  at 
least  usual. 

These  "  punctiform "  wounds  must  have  been 
caused  by  bullets  only  ;  the  insignificant  little  wound 
sometimes  produced  by  a  shell-  or  bomb-fragment  is  as 
serious  as  a  large  wound,  if  not  more  so,  for,  although 
it  appears  a  small  matter  from  the  exterior,  there  are 
extensive  injuries  within. 

What  is  to  decide  whether  we  are  dealing  with  a 
bullet  wound  or  not  ?  The  patient's  own  statement 
is  not  enough,  as  he  may  easily  be  mistaken,  but  a 
careful  examination  will  usually  reveal  the  truth. 

A  bullet  fired  at  long  range  and  entering  nose  first 
leaves  behind  it  no  such  track  of  bruised  tissues  as  is 
caused  by  a  shell-fragment ;  the  skin  wound  is  clean 
and  not  gaping.  Anyone  who  has  seen  a  few  fresh 
wounds  \yill  never  be  mistaken.  A  bullet,  too,  which, 
though  it  may  have  travelled  some  distance,  enters 
with  sufficient  force  to  penetrate  bone,  rarely  remains 
embedded,  it  almost  always  passes  out ;  whereas  a 
small  shell-fragment  usually  remains  in  the  Avound ;  , 
besides  which,  a  wound  of  the  latter  type  is  rarely 
single,  there  being  almost  always  others  somewhere 
in  the  region  of  the  small  wound  corresponding  to  the 
seat  of  the  fracture.  These  distinguishing  charac- 
teristics, slight  as  they  may  seem  at  first,  are  perfectly 
clear,  and  rarely  cause  hesitation. 

Having  said  this,  I  shall  now  only  speak  of  fractures 
caused  by  shell-fragments  or  short-range  bullets. 

In  spite  of  the  infinite  variety  of  metallic  fragments 
t)f  all  kinds,  these  different  fractures  correspond  very 
closely  in  their  features,  and  scarcely  need  be  distin- 
guished. 

I  shall  therefore  study  them  together,  treating  first, 
from  a  general  point  of  view,  of  the  immediate  patho- 
logical anatomy  of  the  seat  of  the  fracture,  then  of  the 
course  of  events  iii  the  injured  area. 

As  the  course  of  events  is  controlled  by  infection,  it 


280 


TREATMENT   OF   FRACTURES 


will  be  well  to  investigate  the  circumstances  contri- 
buting to  infection,  and  the  anatomical  results  of  its 
presence.  A  knowledge  of  what  is  to  be  feared  will 
show  clearly  what  is  to  be  avoided. 

I.   Pathological  Anatomy  of  the  seat  of  a  Fracture  in  its 

earliest  stage 

Every  projectile  striking  the  shaft  of  a  bone  does 
not  of  necessity  fracture  it  :  there  is  no  fracture  unless 
the  continuity  of  the  shaft  is  broken. 

Injuries  by  missiles  which  do  not  cause  solution  of 


Fig.   1, — Transverse         Fig.  2. — The  FiG.  3. — Fracture  with 

fracture.  large-sphnter  type        a  large  short  fragment, 

of  fracture. 

continuity  in  the  long  axis  of  the  bone  are  merely 
wounds  of  the  bone,  whatever  their  form  or  appearance, 
whether  pitting,  furrow,  or  tunnelling. 

Fractures  rightly  so-called  exist  in  infinite  variety, 
and  may  be  roughly  grouped  into  several  types  :  these 
main  groups  can  easily  be  distinguished  after  examin- 
ing a  large  number  of  X-ray  photographs. 


GENERAL  STUDY  OF  SHAFT  FRACTURES   281 

The  four  most  important  are  : 

1.  The  transverse  type  (unusual). — This  fracture 
has  only  one  direction,  resembling  the  result  of  de- 
liberate section  of  the  bone.  It  may  be  slightly  oblique, 
but  is  more  often  exactly  transverse.  This  fracture  is 
usually  produced  by  the  impact  of  a  large  shell-frag- 
ment, almost  spent,  which  enters  the  bone  like  a  wedge. 

2.  The  large-splinter  type  (common).  —  There  is 
considerable  splintering  of  the  bone  in  the  direction  of 
its  length,  with  one  or  two  large  diamond-shaped  frag- 
ments, the  centre  of  which  is  roughly  the  point  of  origin 
of  the  fracture.  In  other  words,  the  two  ends  of  the 
shaft  taper  to  points  which  are  in  contact,  the  splinters 
formed  being  lodged  in  the  angle  which  they  enclose. 
Each  splinter,  about  4  to  6  inches  in  length,  is  some- 
times split  across  its  centre.  There  is  usually  little 
displacement. 

This  tapering  of  the  two  ends  of  the  shaft  is  rarely 
seen  except  in  the  femur  and  humerus. 

3.  The  type  with  a  large  short  fragment  (common). — 
In  this  type,  usual  in  the  ulna  and  tibia,  a  short 
and  broad  Avedge-shaped  fragment  is  detached  from 
the  shaft  and  remains  in  place  between  the  two 
obliquely  pointed  extremities  of  the  shaft.  The 
appearance  of  the  whole  thing  is  that  of  a  horizontal 
V.  Sometimes  two  or  three  small  pieces  are  found, 
like  little  beads,  on  the  side  opposite  to  the  main 
fragment.  There  are  very  often  fissures  extending 
along  the  shaft  in  each  direction. 

4.  The  type  with  mxiny  small  fragments  (common). — 
In  this  fracture  the  shaft  is  shattered  into  a  large 
number  (12,  15,  or  more)  of  small  pieces,  more  or 
less  obviously  radiating  from  the  point  of  impact. 
Some,  from  the  middle  of  the  seat  of  fracture,  are 
entirely  free,  forced  away  some  distance  from  the  bone, 
often  embedded  in  muscles,  thereby  contributing  to 
their  laceration,  and  of  no  regular  shape.  Above  and 
below,  in  contact  with  the  ends  of  the  shaft   fragments 


282 


TREATMENT    OF    FRACTURES 


remain  adherent  to  the  periosteum  or  muscles,  and 
these,  though  fewer  in  number,  are  usually  rather 
larger  than  the  others.  The  general  impression  given 
is  that  a  mass  of  small  fragments  has  been  impelled 
in  the  direction  of  the  exit  wound,  or  at  least  pushed 
by  the  missile  in  front  of  itself. 
There  is  generally  small  debris  em- 
bedded in  the  surrounding  muscles. 
One  of  these  types  will  be  recog- 
nised in  any  fracture  examined  by 
X-rays  or  by  operation. 

Others  might  be  described,  notably 
spiral  fractures  occurring  at  the 
lower  end  of  the  tibia,  or  the  V- 
shaped  fractures  sometimes  seen  in 
the  lower  third  of  the  humerus, 
femur,  and  tibia.  All,  however,  can 
be  relegated  more  or  less  rightly  to 
the  above  categories,  or  else  can  be 
regarded  merely  as  exceptions. 

To    go    into    more     detail :    the 
fractured  area    first   comprises    the 
following  elements  : 

1.  The  Fragments. — These  occur  in  all  sizes  and 
shapes,  from  mere  bone  dust  to  large  diamond-shaped 
fragments  6  inches  long. 

The  smaller  they  are,  the  freer  they  are  found  to 
be  from  all  attachment  to  periosteum  or  muscle,  and 
the  further  they  are  found  from  the  line  of  the  shaft. 
In  general,  small  fragments  are  projected  distally 
towards  the  point  of  exit,  or  more  exactly,  in  the  same 
direction  as  the  track  of  the  missile,  intra-osseous  and 
otherwise. 

This  has  a  practical  result  of  great  importance  :  the 
first  fragments  which  the  projectile  pushes  forward  in 
traversing  the  bone  end  by  embedding  themselves  in 
the  marrow  of  the  shaft  at  some  distance  from  the 
point  of  impact,  aboye  all  in  the  spongy  tissue  of  the 


Fig.  4. — Fracture 
with  many  small 
fragments . 


GENERAL  STUDY  OF  SHAFT  FRACTURES   283 

epiphyses,  thus  evading  discovery  unless  their  actual 
position  is  known.  Virtually  foreign  bodies,  they  re- 
main in  the  middle  of  the  injured  marrow.  Other 
pieces  lacerate  rhuscles  and  remain  embedded  there. 

Given  sufficient  impetus,  they  may  happen  to 
lacerate  vascular  sheaths,  and  come  to  rest  in  contact 
with  arteries  and  veins,  whose  elasticity  deadens  the 
blow  ;  hence  they  are  very  rarely  perforated  by  the 
original  injury.  Nerves,  being  more  resistant,  are 
more  readily  torn  or  severed.  It  is  not  unusual,  for 
instance,  to  find  minute  pieces  of  bone  in  the  sciatic 
nerve. 

'When  the  force  of  the  blow  is  not  so  great,  the  frag- 
ments are  larger  ;   they  remain  more  or  less  attached 
to  the  periosteum  and  surrounding  muscles.     They 
are  lodged  in  the  periphery  of  the  injured  area,  more 
or   less   scattered,    sometimes   diiected   towards   the 
point  of  exit.     The  larger  they  are,  the  more  they 
resist  the  injuring  force  whose  tendency  is  to  displace 
them,  without  actually  freeing  them  altogether  from 
their  ligamentous  and  periosteal  attachments.     The 
most  adherent  are  those  which  an  intact  periosteum 
retains  in  perfect  continuity  with  the  rest  of  the  shaft, 
narrow  fissures  alone  dividing  them  from  it.     There 
are,  in  fact,  all  degrees  between  a  free  fragment,  entirely 
detached,  and  the  most  adherent  one  ;    if  only  two 
extreme  forms  are  distinguished,  no  clear  understand- 
ing of  the  anatomical  details  in  the  fractured  area  is 
likely  to  be  reached  ;  this  arbitrary  distinction  has  ac- 
counted for  regrettable  mistakes  in  treatment,  and  still 
produces  unfortunate  confusion  in  surgical  discussion. 
Small  scraps  of  clothing  often  remain  caught  on  the 
sharp  points  of  long  splinters — not  the  main  piece  of 
material  which  the  projectile  has  carried  before  it 
through  the  bone,  but  shreds  torn  away  as  it  passes. 
They  are  sometimes  embedded  and  scarcely  movable 
in  the  crevice  between  two  very  adherent  fragments, 
and  it  is  exceedingly  difficult  to  detach  them, 


284  TREATMENT    OF    FRACTURES 

The  points  of  splinters,  too,  and  likewise  the  ends 
of  the  shaft,  are  bruised,  crushed,  and  inflamed,  affected 
by  what  is  sometimes  called  traumatic  osteitis  ;  in 
fact,  they  are  more  or  less  devitalised  by  the  force  of 
the  impact. 

In  the  crevices  separating  the  splinters  there  is 
almost  always  a  thin  trail  of  blood-clots,  and  often, 
in  contact  with  them,  metallic  particles  which  had 
accompanied  the  main  shell-fragment. 

A  little  cancellous  tissue,  stained  purplish  or  black 
with  effused  blood,  is  seen  on  the  internal  aspect  of 
almost  all  the  splinters. 

2.  Fissures. — There  are  usually  fissures  travelling 
away  from  the  injured  area,  caused  by  the  spreading 
of  the  projectile  «  energy  on  impact.  In  different  ways, 
according  to  the  intensity  of  this  energy,  and  the 
particular  bone  or  region,  these  fissures,  instead  of 
meeting  and  thus  forming  separate  splinters,  often  run 
parallel  for  a  variable  distance  along  the  shaft  towards 
the  epiphyses.  If  they  are  very  marked.  X-rays  will 
reveal  them,  but  more  often  they  are  only  discovered 
by  careful  direct  examination  ;  some  even  appear  only 
on  transverse  section  of  the  bone. 

In  fractures  occurring  close  to  joints  these  fissures 
are  very  common ;  their  existence  explains  the  appear- 
ance of  joint  symptoms  at  some  distance  from  the 
fracture,  and  accounts  for  certain  complications  to 
which  I  shall  refer  later. 

In  an  aseptic  wound  fissures  are  of  no  consequence, 
and  union  soon  occurs,  nothing  of  them  being  visible 
after  a  few  days.  But  if  there  is  the  slightest  trace  of 
infection  in  the  main  wound,  this  spreads  along  the 
clefts,  and  gradually  reaches  the  joint  cavity,  particu- 
larly in  the  case  of  a  fracture  below  the  epiphysis  of 
the  humerus  or  femur. 

Apart  from  such  fissures,  a  second  fracture  of  the 
shaft  is  occasionally  found  at  some  distance  from  the 
other  and  in  a  healthy  area,  generally  serrated  so  that 


GENERAL  STUDY  OF  SHAFT  FRACTURES   285 


the  ends  fit  with  comparative  accurac} ,     T  have  seen 
this  in  the  humerus  and  femur. 

3.  The  MeduUa.— At  the  level  of  the  track  of  the 
missile,  the  delicate  marrow  seems,  as  it  were,  to 
have  evaporated  ;  no  trace  of  it  is  found  except  a  few 
masses  of  blood-stained  pulp  on  the  inner  side  of  some 
splinters.  But  above,  along  the 
large  fragments  whose  arrange- 
ment indicates  the  position  of 
the  medullary  cavity,  it  is  found 
to  be  torn  up  and  bruised  for  a 
great  distance.  Small  extravasa- 
tions of  blood  are  seen  high  up 
in  the  interior  of  the  shaft,  at 
points  which  would  at  first 
appear  not  to  have  been  affected 
by  the  injury.  These  widespread 
contusions  are  produced  in  the 
same  way  as  the  radiating  fis- 
sures mentioned  above,  and  have 
the  same  untoward  results. 

The  scattering  of  small  splinters 
into  the  medullary  cavity  further 
increases  the  extent  of  the  in- 
jured area,  shattering  the  net- 
work of  cancellous  tissue  and 
leaving  splinters  buried  in  it. 

4.  The  Periosteum. — This  is 
sometimes  destroyed  whei'e  the 
])rojectiIe  has  reduced  the  bone 
to  fine  splinters  and  scattered 
them  widely.  These  lose  their 
periosteum,  but  it  is  a  mistake  to  suppose  that  nothing 
j'emains  of  this  membrane  which  previously  united 
tlieni.  The  periosteum  remains  for  the  most  part  in 
irregilar  fragments  which  at  first  appear  to  maintain 
no  independent  existence.  Further  uj)  the  bone  they 
are  found  to  be  raised  in  places  by  blood-clots  detach e4 


Fig.  5. — Example  of 
fractiu'e  with  long  fis- 
sures. 


286 


TREATMENT   OF   FRACTURES 


by  an  extensive  effusion  of  blood,  or  displaced  by 
muscular  action,  partially  isolated,  in  fact,  from 
fragments  that  have  remained  in  position.     Further 

on,  the  periosteum  is  still  ad- 
herent to  the  fragments  of 
bone,  isolated  and  apparently 
mobile  though  they  may  be  ; 
more  or  less  lacerated  in  the 
region  of  the  fissures,  it  is 
much  more  often  intact 
farther  from  the  seat  of  injury 
than  it  is  believed  to  be.  It 
is  always  delicate,  appearing 
to  be  a  part  of  the  bone ; 
many  surgeons  suppose  that 
it  cannot  be  separated  from 
.the  latter,  and  that  without 
infection  to  thicken  it,  the 
periosteum  is  surgically  non- 
existent. This  conclusion 
saves  them  the  trouble  of  look- 
ing for  it.  But  for  the  care- 
ful operator,  using  the  sharp 
rugine,  the  periosteum  always 
exists,  and  can  always  be 
isolated.  Like  all  fibrous  tis- 
sues, it  is  very  resistant,  and, 
in  the  main,  it  suffers  less  than 
any  other  part  of  the  bone 
from  the  passage  of  the  missile. 
This  is  well  demonstrated 
during  the  operation  for 
sub-periosteal  esquillectomy ; 
when,  approaching  the  fracture 
from  the  exit  wound,  free  splinters,  shreds  of  muscle,  and 
clots  have  been  removed,  and  as  soon  as  one  or  two 
splinters  have  been  detached  that  had  been  maintained 
in  position  by  the  periosteum,  it  is  clearly  seen  that 


Fio.  6. — Double  fracture 
of  the  humerus,  one  direct 
caused  by  a  shell-fragment 
and  a  jagged  indirect  frac- 
ture below  it.  Early  sub- 
periosteal esquiUectoiny  of 
the  fractured  area  has  per- 
miitted  clinically  aseptic 
development.  Continuous 
extension  and  abduction 
applied  below  the  fractures 
has  reduced  the  latter,  and 
union  has  taken  place  with 
a  shortening  of  about  1 
inch. 


GENERAL  STUDY  OF  SHAFT  FRACTURES     287 


the  osseous  space  is  everywhere  defined  by  a  fibrous 
and  opalescent  sheath.  This  sheath  usually  retains 
its  continuity  at  some  point  in  its  circumference  ;  the 
injury  to  it  is  less  considerable  at  the  point  of  entry 
than  at  that  of  exit,  and  it  forms  a  kind  of  mould 
of  the  missing  portion  of  bone.  Unless  great  care 
is  taken,  or  if  those  splinters  are  sharply  pulled  or 
twisted  which  seem  only  weakly  adherent,  but  are 
often  more  tenacious  than  is  sup- 
posed, nothing  of  this  is  seen. 
Fibrous  fragments  float  freely 
about  on  the  confines  of  the  frac- 
ture, becoming  mixed  up  in  shreds 
of  muscle,  and  it  may  be  said 
that  the  periosteum  no  longer 
exists.  This  may  be  so,  but  the 
blame  for  it  lies  with  the  operator. 

Only  in  cases  of  fracture  by  a 
short-range  bullet,  with  powerful 
explosive  effects,  is  there  in  some 
parts  total  destruction  of  the 
periosteum,  and  even  here,  large 
flaps  of  it  are  found,  which  when 
brought,  together  form  a  kind  of 
sheath  with  little  interruption. 

In  brief,  the  region  of  the  frac- 
ture, bounded  by  injured  muscles, 
roughly  assumes  the  shape  of  an 
irregular  spindle.  In  the  centre  is  a  mass  of  clots, 
muscular  debris,  and  small  pieces  of  bone,  arranged 
about  its  transverse  diameter  ;  at  one  extremity  are 
free  splinters  scattered  in  the  soft  parts,  and  converging 
from  the  medullary  cavity  to  a  point  marked  by  the 
exit  wound.  The  entire  picture  is  that  of  a  cone,  its 
base  turned  towards  the  bone,  and  bordered  above 
and  below  by  isolated  osseous  fragments.  The  frag- 
ments still  adherent  to  the  periosteum,  and  connected 
by  it  with  the  shaft,  point  towards  the  exterior  and 


Fig.  7. — Diagram  of 
a  fractiired  area. 


288  TREATMENT    OF    FRACTURES 

form  the  axes  of  the  spindle.  Above  and  below,  their 
periosteum  encloses  the  most  dit^tant  fissures  and  con- 
nects the  fragments  with  the  uninjured  shaft,  some- 
what after  the  manner  of  a  calyx. 

At  the  extremities  of  its  vertical  diameter  contusions 
are  still  found,  little  as  injury  might  be  expected  there. 
Fissures  are  found  in  the  den.se  tissue  of  the  shaft, 
and  the  bone-marrow  is  dark  with  effused  blood. 

When  once  the  space  between  the  bones  is  cleared, 
the  periosteum  remains  like  a  mould  in  two  vertical 
pieces,  completely  encircling  the  injured  area.  But 
it  must  not  be  supj^osed  from  this  that  the  splinters 
form  a  regular  bony  cylinder  whose  removal  will  at 
once  produce  a  corresponding  shortening  of  the  limb. 
More  often,  except  perhaps  in  fractuies  produced  by 
bullets  fired  at  point-blank  range,  only  certain  portions 
of  the  shaft  are  splintered.  The  two  ]:>ointed  ex- 
tremities of  the  shaft  meet  at  their  apex,  and  to  some 
extent  ensure  the  continuity  of  the  bone  without  loss 
of  intervening  osseous  material,  even  after  removal  of 
all  the  splinters. 

5.  Injuries  to  the  Soft  Parts. — Laceration  of  these 
varies  a  great  deal  according  to  the  conditions  of  the 
wound  :  a  small  wound  of  entry  and  a  large  one  of 
exit  with  hernia  of  muscle  in  wounds  by  short-range 
bullets,  a  single  insignificant  wound  from  certain  frag- 
ments of  bomb  or  shell,  the  cutaneous  wound  being 
usually  much  smaller  than  the-  missile  causing  it, 
and  a  large  irregular  and  ragged  wound  caused  by  a 
number  of  separate  shell-fragments. 

The  wounds  are  naturally  not  always  opjjosite  the 
point  of  fracture.  With  different  angles  of  incidence. 
all  directions  are  possible  for  the  track  of  the  missile ; 
when  all  the  possible  different  positions  in  which  the 
limb  may  be  when  the  wound  is  inflicted  are  con- 
sidered, many  curious  results  are  observed. 

The  cutaneous  wounds  are  generally  bounded  by  a 
zone  of  crushed  and  bruised  tissue,  often  impregnated 


GENERAL  STUDY  OF  SHAFT  FRACTURES     289 

with  soil  and  shreds  of  clothing.  Very  shortly  the 
edges  become  distinctly  ragged.  Below  this,  the  fasciae 
are  torn,  often  very  widely,  but  as  a  rule,  particularly 
in  certain  regions  such  as  the  thigh,  the  upper  two- 
thirds  of  the  leg,  and  the  posterior  aspect  of  the  arm 
and  forearm,  the  entry  wound  in  the  fascia  is  small 
and  its  edges  are  rigid  and  stretched,  gripping  a  small 
hernia  of  muscle  which  seems  to  be  trying  to  fill  up 
the  track  of  the  missile. 

When  the  injury  to  the  fascia  is  extensive,  the 
muscles  lie  immediately  beneath  the  skin  ;  they  are 
more  pr  less  lacerated,  and  rapidly  assume  the  appear- 
ance of  gangrenous  tissue,  and  often  have  an  unpleas- 
ant friable  granular  feeling  to  the  touch.  Small 
thrombosed  veins  and  blood-clots  are  found  beneath 
the  skin  and  along  the  muscles.  The  more  or  less 
gangrenous  muscle  constitutes  a  curtain  hiding  the 
end  of  the  track  where  the  fracture  is  situated.  In  the 
exit  wound  the  injury  is  more  extensive,  and  fragments 
of  bone,  scattered  by  the  violence  of  the  im2)act,  aug- 
ment the  damage  caused  by  the  missile  itself. 

Muscular  involvement  extends  some  distance  from 
the  region  of  the  track  ;  sheaths  are  infiltrated  with 
blood  and  loosened ;  fibres  severed  by  the  missile 
retract  towards  their  insertions,  extending  the  effects 
of  the  injury  for  a  considerable  distance.  These  are 
the  chief  features :  widespread  muscular  injuries, 
interstitial  haemorrhage  here  and  there  and  slight 
evidences  of  explosive  effects,  encountered  sometimes 
at  points  that  seem  astonishingly  remote,  even  to  one 
accustomed  to  finding  them. 

Blood-vessels  and  nerves  are  usually  uninjured. 

Primary  injuries  of  vessels  are  in  the  main  unusual, 
except  in  the  arteries  of  the  forearm.  Laceration 
sometimes  occurs  in  the  femoral  artery  in  fractures  of 
the  upper  end  of  the  femur,  in  the  brachial  in  the  upper 
part  of  the  arm,  and  in  the  posterior  tibial  high  up  in 
the  leg.     Haemorrhage,  however,  is  not  often  extensive. 


290  TREATMENT    OF    FRACTURES 

and  many  injured  vessels  do  not  even  bleed  at  all, 
and  the  lesion  escapes  notice  at  first  unless  they  are 
disturbed.  There  are  no  doubt  many  which  do  bleed, 
but  such  cases  die  before  reaching  an  ambulance. 
Though  actual  wounds  of  vessels  are  unusual,  arterial 
contusions  are  far  from  being  so.  In  aseptic  wounds 
they  heal  without  giving  rise  to  any  particular  symp- 
toms, but  if  there  is  any  infection,  a  diseased  patch 
develops,  and  subsequent  ulceration  may  lead  to  fatal 
secondary  haemorrhage. 

.Nerve  lesions  are  more  common.  Taking  all  war- 
wounds  together,  however,  this  complication  is  an 
unusual  one.  It  is  difficult  to  state  an  exact  propor- 
tion, since  a  good  deal  of  traumatic  paralysis  may 
escape  recognition  during  a  large  influx  of  cases. 
I  have  counted  barely  8  per  cent.,  but  this  figure  is 
valueless.  There  are  some  fractures  which  never 
involve  nervous  lesions,  and  others  in  which  they  are 
a  common  feature  ;  that  of  the  upper  third  of  the 
humerus,  for  instance,  causes,  in  my  experience, 
radial  (musculo-spiral)  paralysis  in  16  to  18  per  cent, 
of  cases.  Ulnar  paralysis  often  complicates  fracture 
of  the  ulna,  and  sciatic  paralysis  sub-troehanteric 
fracture  of  the  femur.  The  injury  to  the  nerve  is 
almost  always  caused  by  the  missile  and  not  by 
splinters. 

6.  Displacement  and  Over-riding. — There  is  usually 
little  displacement  in  these  fractures,  relatively  at 
least  to  the  amount  commonly  seen  in  civil  practice, 
although  the  fracture  extremities  do  not  fit,  and  there 
is  always  damage  to  the  periosteum  ;  in  some  fractures 
there  is  no  initial  displacement  whatever,  since  the 
partial  destruction  of  muscles  and  tendinous  inser- 
tions prevents  the  exertion  of  any  pull  on  the  frag- 
ments of  the  shaft.  At  times,  on  the  other  hand, 
there  is  marked  displacement :  it  may  occur  in  any 
direction,  according  to  the  general  position  of  the 
bone  or  bones  ;  sometimes  it  produces  angulation  in 


GENERAL  STUDY  OF  SHAFT  FRACTURES     291 

the  thickness  of  the  limb  (common  in  the  u^jper 
third  of  the  forearm),  sometimes  it  produces  a  sort 
of  bayonet  deformity  (common  in  the  leg) ;  where  two 
bones  are  involved,  displacement  often  takes  the  form 
of  convergence  between  them,  if  the  fracture  occurs 
in  the  middle  of  the  shafts  (in  leg  and  forearm). 
Finally,  a  frequent  effect  is  the  rotatory  displacement 
of  the  two  ends  of  the  shaft  in  opposite  directions, 
resulting  from  the  action  of  antagonistic  muscles, 
exemplifying  what  Destot  described  in  civil  practice 
as  "  decalage  "  :  this  occurs  most  typically  in  the 
forearm,  the  upper  radial  fragment  being  rotated 
outwards  by  the  supinating  effect  of  the  biceps  and 
supinator  brevis,  while  the  pronators  induce  marked 
pronation  in  the  lower  fragment ;  the  phenomenon 
occurs  in  some  degree,  however,  almost  anywhere. 

Over-riding,  which  is  only  longitudinal  displacement, 
is  never  marked  except  in  the  arm  and  thigh.  Here, 
however,  it  is  often  considerable,  and  the  opposed 
fragments  are  distinctly  pointed;  the  muscles,  in 
spite  of  their  injuries,  are  still  powerful  enough  to  pull 
the  lower  fragment  forcibly  upwards,  thus  piercing 
the  muscles  and  carrying  with  it  a  few  large  splinters 
which  remain  interposed  between  the  two  ends  of  the 
shaft.  In  fractures  high  up  in  the  thigh,  the  upper 
fragment  almost  always  undergoes  abduction  and 
external  rotation.  Similarly  in  the  upper  part  of 
the  humerus,  if  the  fracture  occurs  below  the  insertion 
of  the  deltoid,  the  proximal  end  is  carried  upwards, 
out  war  do,  and  backwards,  while  the  lower  suffers 
internal  rotation  with  a  variable  amount  of  displace- 
ment towards  the  axilla. 

This  may  be  summed  up  in  the  following  way : 
whatever  the  type  of  fracture,  its  effects  are  always 
very  widespread  ;  injury  extends  much  further  than 
might  be  supposed ;  in  the  centre  of  the  injured  area 
is  a  mass  of  clots,  muscular  debris,  and  free  splinters 
of  bone  ;  above  and  below  it  are  fragments  more  or  less 


292  TREATMENT   OF   FRACTURES 

displaced,  but  still  attached  to  periosteum  or  muscle ; 
some,  where  periosteum  has  proved  resistant  and  still 
invests  them,  retain  their  position  in  relation  to  the 
shaft,  the  sharp  points  of  which  are  generally  in  con- 
tact with  those  of  the  opposite  side.  Fissures  in  the 
shaft  itself  prolong  the  injury  further.  Withm  the 
medullary  canal,  part  of  whose  contents  is  gone 
completely,  is  found  a  mixture  of  blood-stained  pulp 
and  isolated  splinters  without  muscular  attachment 
and  destined  ultimately  to  undergo  necrosis. 

The  fractured  area  is  not  usually  in  a  straight  line  ; 
displacement  and  over-riding,  however,  are  often 
not  serious.  All  the  surrounding  muscles  are  bruised 
and  lacerated,  but  they  still  function  and  approximate 
again  after  the  missile  has  passed,  completely  enclosing 
the  region  of  the  fracture. 


n.   Immediate  results  of  Fracture,  and  the  normal  course 

to  recovery 

Violent  local  injury  producing  the  effects  described 
above  gives  rise  to  a  very  variable  immediate  reaction 
on  the  system  generally. 

Some  cases  show  practically  none,  and  exhibit  no 
signs  of  shock ;  the  patients  remain  upright  and  retain 
consciousness.  In  the  majority  of  cases  it  is  otherwise, 
as  the  initial  loss  of  blood  is  considerable.  At  the  aid- 
post  and  in  the  field  ambulance,  haemorrhage  is  so 
profuse  that  serious  vascular  injury  is  instinctively 
suspected  by  the  less  experienced  ;  this  explains  a 
good  deal  of  the  useless  application  of  tourniquets. 
Pain  and  loss  of  blood  combine  to  produce  depression 
which  subsequently  disappears  if  the  preliminary  steps 
are  taken  promptly.  Very  frequently,  too,  particu- 
larly in  fractures  of  the  lower  limb  and  sometimes 
after  very  slight  loss  of  blood,  severe  symptoms  of 
shock    are    present — pallor,    lividity,    coldness,    and 


GENERAL  STUDY  OF  SHAFT  FRACTURES     293 

shivering,  sometimes  dyspnoea  and  a  feeble  rapid  pulse 
— the  typical  picture  of  shock. 

This  is  not  the  result  of  infection,  and  does  not 
indicate  acute  septicaemia,  as  is  sometimes  stated ;  it 
appears  at  once,  before  any  infection  could  have 
developed,  and  is,  indeed,  noticed  chiefly  in  cases  which 
recover  without  sepsis  under  suitable  treatment ; 
shock  is  therefore  not  an  evidence  of  septicaemia.  It 
is  apparently  the  result  of  sudden  vasomotor  disturb- 
ance following  pain  reflexes  from  the  wound,  of  haemor- 
rhage, and,  above  all,  of  sudden  injury  to  branches  of 
the  sympathetic  system,  resulting  in  violent  peripheral 
vaso-constriction,  and  corresponding  dilatation  of  the 
abdominal  vessels. 

As  soon  as  the  pain  has  passed  off  and  immobility 
of  the  injured  region  has  been  ensured,  the  disturbances 
in  the  sympathetic  system  automatically  and  easily 
right  themselves,  producing  excellent  physiological 
conditions  for  spontaneous  recovery,  should  the  injury- 
remain  aseptic. 

There  are,  in  fact,  all  necessary  elements  for  rapid 
callus  jormation  within  the  wound  itself  :  an  active 
periosteum,  stimulated  by  the  bleeding,  enclosing 
adherent  and  free  bone  fragments  which  are  almost 
comparable  to  grafted  bone,  marrow  scattered  all 
round  the  shaft  and  amongst  the  muscles  and  deep 
cellular  tissue,  ready  to  take  part  in  bone  formation. 
In  a  few  days  a  resistant  enclosing  belt  is  formed, 
within  the  protection  of  which  the  normal  processes  of 
repair  can  continue,  as  in  a  simple  fracture. 

Union  is  often  singularly  rapid  ;  I  have  seen  a  frac- 
tured femur  unite  in  twenty-five  days  ;  but  the  callus 
is  not  yet  firm  at  this  stage,  and  can  generally  be 
broken  down  by  hand  under  an  anaesthetic.  Slowly 
and  little  by  little  its  substance  becomes  definitely 
organised  until  the  formation  of  the  original  bone  is 
reproduced. 

Unfortunately  such  aseptic  development  is  a  very 


294         TREATMENT   OF   FRACTURES 

rare  exception,  occurring  only  in  fractures  by  bullets 
which  have  produced  only  punctiform  skin- wounds. 
In  other  fractures,  infection  is  the  rule,  and  uninter- 
rupted progress  vnth  asepsis  an  exception  which  should 
never  be  relied  on,  although  it  sometimes  occurs.  For 
practical  purposes  it  should  be  assumed  that  such 
simple  and  ideal  development  never  occurs  in  fractures 
by  fragments  of  shell,  bomb,  torpedo  or  short-range 
bullets  :  war- fractures  are  almost  always  infected  at  the 
outset. 

Now,  without  referring  to  other  risks  which  it  in- 
volves, infection  seriously  interferes  with  the  normal 
progress  of  union :  it  is  a  very  frequent  cause  of 
pathological  callus. 

Neither  is  a  united  fracture  necessarily  c*  cured  frac- 
ture. 

The  cure  of  a  fracture  requires  union  by  healthy 
callus  with  the  fragments  of  the  shaft  in,  line  with  the 
normal  axis  of  the  limb,  so  that  forces  brought  to  bear 
on  the  arm  of  the  lever  may  produce  the  usual  results, 
and  the  physiology  of  the  limb  not  be  affected.  If  dis- 
placement is  not  corrected,  and  the  union  is  anatomic- 
ally faulty,  there  is  every  likelihood  that  it  will  be 
physiologically  faulty  also,  and  the  word  cure  in  its 
true  sense  can  hardly  be  used. 

In  other  words,  war-fractures  which  possess  all  the 
elements  necessary  for  prompt  recovery,  possess  too 
the  potentialities  of  a  vicious  pathological  or  faulty 
union.  It  is  essential  to  a  cure  to  have  an  exact  under- 
standing of  the  causes  of  these  pathological  develop- 
ments. Only  such  knowledge  can  direct  treatment 
which  consistently  results  in  that  ideal  cure,  the  only 
result  which  repays  a  systematic  endeavour. 

m.   Patbological  changes  in  a  Fracture 

1.  Infectioii  and  its  results.  —  Infection  interferes 
with  normal  progress  by  modifying  the  activity  of 


GENERAL  STUDY  OF  SHAFT  FRACTURES     295 

osteogenetic  tissue,  exciting,  killing,  or  inhibiting  it. 
The  majority  of  bad  unions  result  from  this.  Mechani- 
cal factors  are  much  less  important. 

A.  Causes  and  conditions  of  Infection. — In 
practice  infection  always  comes  from  the  outside  :  it 
enters  with  the  missile  and  anything  carried  in  by  the 
latter.  Doubtless  the  condition  of  the  skin  is  not 
theoretically  without  its  effect,  and  it  would  be  absurd 
to  deny  the  importance  of  prolonged  contact  between 
a  fresh  wound  and  the  ground  or  dirty  clothing,  par- 
ticularly in  wet  weather.  But  these  are  only  secon- 
dary causes  of  sepsis  :  the  spread  of  infection  begins 
deep,  when  the  skin  and  subcutaneous  tissues  are 
still  healthy  ;  it  arises  below  the  outer  muscular  layer, 
in  the  spot  where  the  shell-fragment  is  lodged,  with 
shreds  of  clothing  and  pieces  of  stone  and  wood  which 
it  has  carried  with  it. 

Much  research  during  the  war  has  shown  that 
bacterial  activity  begins  around  the  pieces  of  clothing 
between  the  ninth  and  tenth  hour  (Policard).  There 
is  nothing  on  the  surface  for  some  time.  The  point 
is  therefore  proved. 

Bacteria  concerned. — The  first  organisms  to  multiply 
are  the  vibrion  septique  and  B.  perfringens  {Aerogenes 
capsulatus)  ;  between  the  sixteenth  and  twenty- 
fourth  hours  the  streptococci,  staphylocx)cci,  and 
pneumococci  appear,  and  thenceforward  the  flora  of 
any  wound  remain  very  complex.  In  a  general  way 
it  jnay  be  said  that  any  wound  is  infected  in  every 
possible  way  at  the  outset,  although  nothing  of  this 
can  be  determined  at  that  stage. 

Factors  controlling  the  seriousness  of  an  injection. — 
Though  all  fractures  are  generally  infected  in  much  the 
same  way,  the  results  are  not  always  the  same. 
Numerous  factors  influence  the  infecting  organisms, 
increasing  or  modifying  their  vuulehce  :  great  varia- 
tions exist  in  every  group  of  bacteria,  and  certain 
factors  which  Wright  has  described  may  intervene  in 


296  TREATMENT    OF    FRACTURES 

situ.  In  practice,  from  the  surgical  point  of  view, 
and  particularly  in  the  case  of  shaft  fractures,  there 
are  only  two  definite  factors  which  determine  the 
seriousness  of  the  infect ion^ — the  extent  of  muscular 
destruction,  and  the  existence  of  anatomical  conditions 
producing  complete  enclosure. 

Destruction  of  muscles  is  a  constant  feature  in  the 
region  of  the  injury,  but  it  varies  in  extent.  Some- 
times it  is  confined  to  the  immediate  neighbourhood 
of  the  missile's  track,  and  muscles  in  contact  with  the 
bone  are  uninjured.  Jn  any  case,  and  more  usually, 
the  injury  to  musclfes  is  considerable,  out  of  all  pro- 
portion to  the  size  of  the  shell-fragment  :  at  a  great 
distance  from  the  seat  of  the  fracture  and  the  track  of 
the  missile,  muscles  are  split  and  destroyed,  and  vessels 
are  thrombosed  ;  oedematous  infiltration  of  the  peri- 
osteum is  found  where  it  is  least  expected.  There  is 
wild  and  indiscriminate  destruction,  muscle  being 
devitalised  so  as  to  produce  a  perfect  medium  for 
bacterial  growth.  Immediately  surrounding  the  frac- 
ture there  is  little  else  but  muscular  debris,  and  it  is 
in  the  region  of  this  ready-made  incubating  area, 
strewn  with  foreign  debris  and  shreds  of  clothing, 
that  the  infection  develops. 

The  essential  gravity  of  these  cases  will  be  under- 
stood, particularly  where  the  track  is  very  oblique 
and  the  damage  to  muscle  is  consequently  very  ex- 
tensive. 

These  features  are  most  marked  in  certain  regions, 
the  thigh,  the  neighbourhood  of  the  triceps  brachialis, 
the  antero-lateral  compartment  of  the  leg,  and  wher- 
ever tough  fasciae  completely  enclose  the  muscular 
bellies.  On  the  other  hand,  where  there  is  no  muscle, 
the  development  of  severe  sepsis  is  unusual. 

Other  factors,  however,  influence  the  course  of  the 
infection. 

In  fractures  of  superficial  bones,  with  a  widely  open 
wound,  the  infection  is  not  a  serious  matter,  even  if 


GENERA  L  STUD  Y  OF  SUA  FT  FRACTURES     297 

soil  and  pieces  uf  clothing  are  in  contact  with  the 
broken  bones.  On  the  other  hand,  it  is  very  serious 
when  a  deeply  seated  bone  is  buried  in  powerful 
muscles  which  enclose  the  region  of  the  fracture,  and 
where  the  latter  is  closely  and  firmly  surrounded  to 
the  exclusion  of  air  and  light.  In  other  words,  the 
worst  infections  develop  where  a  completely  enclosed 
area  is  produced.  This  fundamental  proposition  is  a 
clinical  fact  which  it  would  be  idle  to  substantiate  ;  it 
is  not  original ;  the  classical  term  "  debridement," 
which  describes  the  essential  process  of  war  surgery, 
in  itself  proves  how  old  this  clinical  axiom  is. 

Again,  this  enclosed  area  favourable  to  sepsis  is 
quickly  reinforced  by  it :  from  the  earliest  stages  of 
protective  reaction,  even  before  infection  has  begun 
to  develop,  the  rigidity  of  the  injured  area  increases, 
the  swollen  and  oedematous  muscle  closing  more 
completely  than  ever  the  region  of  osseous  and  muscu- 
lar destruction,  which  becomes  a  perfect  incubator  : 
to  the  favourable  anatomical  conditions  of  enclosure, 
pathological  conditions  are  added,  and  the  development 
becomes  still  more  rapid,  and  hourly  more  formidable 
and  dangerous. 

B.  Results  of  Infection. — If  clearance  and  ex- 
posure of  the  region  are  not  rapidly  effected,  sepsis 
produces  most  serious  anatomical  and  clinical  results  ; 
sometimes  death  ensues  so  rapidly  that  the  spread  of 
sepsis  has  hardly  time  to  develop  and  its  anatomical 
results  are  negligible  ;  more  frequently  things  are 
otherwise,  and  the  local  effects  of  sepsis  control  the 
clinical  progress  of  the  fracture. 

I  shall  divide  these  results  into  three  main  classes  : — 

I.  Septicremia. — Theoretically,  the  rapid  develop- 
ment of  infection  in  a  wound  ])resenting  a  large  absorb- 
ing surface  may  be  followed  by  acute  septicaemia.  In 
practice  it  is  very  rare,  and  septicaemia  is  not  encoun- 
tered. So  far,  it  has  scarcely  been  proved  by  bacterio- 
logical   methods  :     blood-cultures,    though   frequently 


298         TREATMENT    OF    FRACTURES 

made,  have  very  rarely  given  any  results,  except  in 
the  last  moments  of  life,  and  clinically,  rapid  deaths, 
sometimes  attributed  to  very  severe  septicaemia,  are 
much  more  probably  caused  by  the  absorption  of  toxic 
products  of  muscular  necrosis  which  plays  so  impor- 
tant a  part  in  influencing  the  earlier  symptoms. 

The  proof  of  this  is  that  thorough  cleansing  of  the 
area  and  the  surgical  removal  of  all  devitalised  tissue 
(the  latter  augmenting  the  absorbent  surface  and 
poisoning  effect)  abolish  all  evidence  and  likelihood 
of  toxaemia,  after  which  secondary  visceral  lesions, 
such  as  would  certainly  appear  had  there  been  a  general 
infection  from  the  outset,  are  never  seen. 

2.  Gas  gangrene. — This  is  the  most  formidable  and 
common  infection  which  develops  in  fractured  areas. 
It  is  not  usually  a  septicaemia  ;  in  spite  of  the  gravity 
of  the  general  symptoms  the  initial  lesion  is  definitely 
localised.  So  large  a  number  of  bacteriological  and 
clinical  forms  have  been  described  that  it  is  difficult 
to  know  where  one  is.  In  my  opinion,  it  is  the  anatomi- 
cal localisation  of  the  primary  focus  of  infection,  and 
not  any  specific  form  of  organism,  that  really  deter- 
mines the  clinical  form  of  the  affection  ;  phlegmonous 
erysipelas,  diffuse  gaseous  cellulitis,  or  true  gas  gan- 
grene arise  according  as  the  infection  is  cutaneous, 
subcutaneous,  or  deep  in  the  muscles.  In  fractures 
the  deep  form  is  usually  found,  that  is  to  say,  true  gas 
gangrene,  rapidly  progressing  and  soon  complete. 

The  fracture  itself  is  not  responsible  for  this  ;  it  is 
the  muscular  injuries  in  an  enclosed  area  which  are 
the  primary  factor  in  the  infective  development. 
Injured  bone  plays  no  part  except  in  augmenting 
muscular  injury  (laceration  by  scattered  splinters), 
and  in  contributing  to  produce  necessary  local  con- 
ditions by  detaching  muscles  from  their  insertions. 

Gas  gangrene  is  not  a  mysterious  phenomenon  whose 
pernicious  effects  are  not  to  be  escaped  from  :  it  should 
be  regarded  as  a  gangrene,  chiefly  mechanical  in  origin 


GENERAL  STUDY  OF  SHAFT  FRACTURES     299 

resultirg  from  interference  with  the  blood-supply, 
of  otherwise  healthy  muscular  tissue,  this  effect  being 
due  to  the  pressure  of  gas  produced  by  histolytic 
organisms  in  a  closed  muscular  wound,*  or  by  the  dis- 
integration of  muscle.  Amongst  the  organisms  found 
in  such  an  injury,  a  certain  number,  or  at  least  B. 
aerogenes  capsulatus,  are  capable  of  producing  gas, 
and  it  appears  that  the  disintegration  of  muscle  favours 
this  process.  The  gases  in  themselves  are  not  poi- 
sonous ;  their  pressure  is  merely  evidence  of  bacterial 
activity.  If  the  wound  is  closed,  it  cannot  escape,  and 
spreads  into  the  sheaths  of  the  muscles  surrounding 
its  incubating  chamber.  The  distension  which  follows 
closes  the  deep  wound  even  more  firmly,  and  blocks 
every  way  of  escape  ;  the  pressure  increases  fatally  ; 
capillaries  are  compressed,  and  the  circulation,  even 
in  parts  which  are  still  unaffected,  is  stopped,  and  in 
this  way  an  acute  gangrene  is  mechanically  produced 
in  the  infected  area. 

Owing  to  the  fascicular  arrangement  of  the  muscles, 
the  progress  of  the  gas  continues,  causing  extension  of 
the  gangrene,  whose  products  of  decomposition  are 
absorbed,  causing  serious  toxaemia  which  presents  the 
clinical  features  of  septicaemia. 

There  may  be  other  forms  of  gaseous  infection,  but 
I  believe  that  true  gas  gangrene  complicating  fractures 
is  almost  always  a  gangrene  produced  mechanically 
by  impaired  circulation,  gas  under  pressure  directly 
causing  obliteration  of  capillaries*  and  producing  gan- 
grene which  results  in  death  from  toxaemia. 

In  brief,  gas  gangrene,  or  rather  gangrene  caused  by 
gas,  is  a  purely  local  complication  of  the  infection  of 
muscular  wounds  accompanying  fractures.  And  local 
treatment,  if  sufficiently  comprehensive  to  clear  out 
the  area  of  muscular  destruction  including  the  closed 

*  The  bacteriological  researches  of  Kenneth  Taylor  confirm  at 
all  points  the  theories  developed  here  of  the  mode  of  action  of  gas 
gangrene. 


;300  TREATMENT    OF    FRACTURES 

cavity,  is  always  sufficient  prevention,  should  signs 
of  the  infection  appear  early. 

3.  Osteomyelitis  and  its  results  :  the  pathology  of  the 
Callus. — Infection  of  the  bone  is  the  most  character- 
istic complication  in  fractures  which  have  escaped  the 
formidable  consequences  of  muscular  infection  in  a 
closed  cavity  (gangrene  caused  by  gas). 

Direct  infection  of  the  seat  of  the  fracture  and  of 
the  bone-marrow  is  a  constant  feature  of  all  fractures 
where  asepsis  has  not  been  ensured  by  operative 
interference.  Bacteria  find  the  conditions  here  the 
more  favourable  since  there  are  more  clots,  muscular 
debris  and  fine  bone  particles  in  contact  with  the  shell 
fragments  and  scraps  of  clothing,  since  large  splinters 
surround  the  area,  since  more  fissures  exist,  and  finally 
since  the  wound  is  less  directly  open  to  the  exterior. 

At  any  rate,  the  ends  of  the  bone,  bruised,  and  affected 
by  traumatic  osteitis,  as  the  older  writers  called  it, 
rapidly  become  infected  :  suppuration  begins  on  their 
surface,  at  first  slight,  but  later  more  and  more  profuse, 
the  first  result  of  which  is  to  precipitate  the  necrosis 
of  any  parts  whose  vitality  is  diminished,  the  struc- 
tures thus  necrosed  fui'ther  helping*  to  increase  sup- 
puration. 

(a)  Free  fragments,  which  in  a  clean  wound  would 
have  been  so  many  active  grafts,  rapidly  become 
sequestra  which  suppuration  tends  to  eliminate. 

Partly  detached  splinters,  which  only  retain  slight 
vascular  connections  with  bone  and  muscles,  lose 
these  by  thrombosis  of  their  vessels,  and  become  so 
many  fresh  sequestra  whose  presence  stimulates 
infection  and  largely  augments  pus-formation.  This 
spreads  along  the  extremities  of  the  shaft,  and  a 
regular  vicious  circle  is  introduced,  suppuration  increas- 
ing in  order  to  eliminate  debris  the  necrosis  of  whicli 
it  has  itself  produced. 

Firmly  adherent  splinters,  whose  vitality  at  first 
appeared  sufficient,  rapidly  become  diseased  under  the 


GENERAL  STUDY  OF  SHAFT  FRACTURES    301 

influence  of  seijsis  ;  the  infection  spreads  along  the 
fissures  bounding  them,  involving  them  in  a  continuous 
layer  of  leucocytes,  which  soon  develop  into  fleshy 
granulations ;  their  presence  obstructs  vessels  and 
displaces  the  fragments,  to  such  an  extent  that  soon 
they  are  nothing  more  than  fragments  of  inflamed 
bone  ;  they  are  rough  to  the  touch,  with  periosteal 
new  deposits  on  their  surfaces,  not  dead  white  like 
traumatic  sequestra,  but  showing  red  patches  as  in 
sequestra  from  osteitis  ;   these  splinters  slowly  die. 

It  is  true  that  this  is  not  always  so  ;  there  are  many 
adherent  spjinters  which  resist  infection  and  become 
incorporated  in  the  callus,  but  the  reverse  is  much  more 
common.  In  all  fractures  which  have  been  insuffi- 
ciently cleared  out,  and  have  suppurated  for  any 
length  of  time,  osteitis  in  the  adherent  fragments  is 
the  rule.  The  majority  work  out  sooner  or  later ; 
the  others  remain  diseased,  and  cause  the  persistence 
of  sinuses,  with  considerable  pain  at  the  level  of  the 
fracture.  Apart  from  fractures  by  shrapnel,  and  a 
few  favourable  cases  by  shell-fragments,  it  could 
almost  be  said  that  the  only  difference  between  free 
and  adherent  splinters  lies  in  the  length  of  time 
elapsing  before  they  make  their  way  out.  In  any  case 
there  are  numbers  of  wounded  at  the  bases  who  collect 
in  a  box  the  splinters  which  their  medical  officer 
has  carefully  preserved,  and  which  have  come  to  the 
surface  in  the  pus.  Exaggeration,  however,  must  be 
avoided.  The  one  important  fact  to  remember  is  that 
in  septic  wounds  which  are  not  speedily  cleansed,  few 
splinters  escape  osteitis. 

Sepsis  has  also  a  deleterious  effect  on  all  the  con- 
stituents of  the  broken  shaft. 

{h)  The  hone-marrow,  biologically  the  most  delicate 
of  them,  is  the  first  to  be  affected  and  killed  ;  it  is 
invariably  affected  to  some  extent. 

During  the  early  stages  of  less  serious  cases,  this  is 
evidenced  by  the  formation  of  a  pur])lisb  protrusion 


302  TREATMENT    OF    FRACTURES 

blocking  the  medullary  canal  ;  this  plug  does  not 
bleed,  and  is  easily  displaced  by  the  finger,  leaving*  a 
marked  hollow  space  in  the  canal.  This  is  seen  well 
in  X-ray  photographs  ;  the  medullary  cavity  above 
and  below  the  fractured  area  is  apparently  empty, 
seeming  more  translucent  than  the  rest  of  the  bone. 

When  the  sepsis  is  more  marked,  medullary  infec- 
tion spreads  much  further,  sometimes  traversing  the 
whole  length  of  the  shaft,  even  reaching  the  epiphysis  ; 
infection  of  the  joint  sometimes  occurs  along  some 
unusual  track. 

Later  the  disease  and  death  of  the  marrow  are  evi- 
denced by  the  formation  of  more  or  less  considerable 
sequestra  from  the  ends  of  the  shaft.  It  occurs  in 
this  way  :  where  the  medullary  plug  is  formed  the 
vessels  are  obliterated,  some  of  them  supply  the 
compact  b9ne  surrounding  the  medullary  canal  and 
the  destruction  of  these  vessels  leads  to  necrosis  of  the 
whole  circumference  of  the  bone.  On  examination,  a 
sequestrum  is  found  in  the  form  of  a  regularly  serrated 
ring  ;  the  projections  are  formed  at  the  expense  of 
the  bone  enclosing  the  medullary  cavity  in  the  whole 
of  its  circumference.  Later  this  sequestrum  breaks 
up  into  numerous  jagged  and  irregular  pieces  which 
have  no  characteristic  appearance.  This  formation  of 
pseudo-fragments  as  a  result  of  osteitis  of  the  ends  of 
the  shaft  should  be  well  understood.  The  fragments 
are  not  traumatic  splinters,  but  sequestra  produced  by 
medullary  infection,  or  osteomyelitis  in  the  true  sense 
of  the  term.  They  work  out  gradually  if  the  callus 
has  not  already  formed,  and  sometimes  the  osteitis 
disappears,  but  much  more  often,  when  the  infection 
of  the  bone  marrow  is  more  serious  and  extensive,  the 
results  are  entirely  different ;  the  marrow  being 
destroyed  for  a  great  distance,  a  more  or  less  extensive 
cavity  remains  in  the  centre  of  the  embryonic  callus, 
which  is  not  filled  up  by  anything,  and  the  periosteum, 
still  adherent  to  splinters  displaced  l^y  the  injury,  forms 


GENERAL  STUDY  OF  SHAFT  FRACTURES    303 


a  callus  outside  the  long  axis  of  the  shaft.  During 
this  time  the  marrow,  proliferating  outside  the  area 
of  medullary  destruction,  forms  a  plug  of  condens- 
ing osteitis  which  entirely  shuts  off    the    medullary 


Figs.  8  and  9. — Sketch  of  a  femur  amputated  after  the  fracture, 
which  had  not  been  subjected  to  sub-periosteal  esquillectomy,  and 
had  suppurated  for  nine  months.  It  will  be  noticed  that  the  callus 
extends  beyond  the  shaft  {i.e.  is  wider),  that  it  surrounds  a  hollow 
cavity,  and  that  ossification  occurring  round  adherent  splinters  has 
left  an  infected  caxity  whose  obliteration  is  impossible.  In  the 
diagram  the  medullary  canal  is  seen  to  be  closed  at  each  end, 
and  there  are  two  openings  (o).  After  nine  months,  suppxirative 
arthritis  developed  in  the  knee-joint. 

canal.  Thenceforward  the  cavity  is  closed  and 
bounded  by  rigid  and  inextensible  walls,  a  condition 
which   is   intrinsically    incurable,  none   of    the   walls 


304  TREATMENT    OF    FRACTURES 

being  able  to  come  into  contact  with  one  another.  At 
each  end  of  this  cavity,  in  which  infection  persists,  the 
diseased  ends  of  the  shaft  continue  to  produce  in- 
flammatory sequestra,  whose  piesence  promotes  con- 
tinued suppuration. 

Cases  are  thus  seen  with  a  large  callus  completely 
surrounding  a  closed  infected  area,  with  no  outlet  to 
the  exterior  except  sinuses  which  cannot  be  cleansed. 

Sometimes  closure  of  the  external  wound  occurs 
after  removal  or  elimination  of  a  sequestrum,  but  a 
fresh  sinus  soon  develops,  showing  that  another 
sequestrum  has  formed  and,  being  imprisoned,  tries 
to  escape. 

The  track  of  a  fistula  through  the  soft  parts  is  hard 
and  lardaceous,  and  its  walls  are  not  elastic.  Outside, 
round  the  external  opening,  the  skin  is  purplish  and 
shining.  There  is  a  tendency  for  cicatrisation  to 
spread  up  the  opening,  and  sometimes  actual  tunnels  of 
epidermis,  2|  inches  in  length,  are  removed,  but  cure 
is  still  far  distant,  such  cases  being  doomed  to  a  suc- 
cession of  operative  interferences  without  any  guarantee 
of  a  satisfactory  ultimate  recovery. 

This  is  a  course  frequently  taken  by  disease  of  the 
bone-marrow,  but  it  is  not  the  only  course. 

Sometimes  when  the  medullary  canal  has  been 
exposed  by  the  missile  (and  particularly,  J  have 
found,  when  the  continuity  of  the  shaft  has  not  been 
broken),  a  condensing  osteitis  appears  which  thickens 
the  bone  enormously  and  tends  to  obliterate  the 
medullary  canal,  the  bone  becoming  as  dense  as  in  a 
case  of  rickets.  This  large  ivory-like  mass  is  often 
the  seat  of  a  periphei'al  osteitis  :  eroding  abscesses 
aie  formed  which  can  be  cuied  by  small  incisions, 
leaving  a  limb  I'iddled  with  scars,  with  stiff  sclerosed 
muscles,  hardened  fasciie,  and  thrombosis  in  many 
of  the  smaller  vessels. 

X-rays  show  a  oomjoact  mass,  in  which  no  structural 
details  are  visible.     This   is  seen   in   the  femur  and 


GENERAL  STUDY  OF  SHAFT  FRACTURES     305 

tibia  ;  at  least  I  have  not  seen  it  elsewhere.  Its 
pathological  anatomy  is  best  studied  in  the  tibia ; 
here  condensing  osteitis,  causing  hypertrophy  of  the 
bone,  mechanically  prevents  the  healing  of  the  stiff 
and  lardaceous  surrounding  parts.  Deep  grooves 
must  be  gouged  in  the  dense  bone,  great  quantities 
being  removed  before  there  is  even  a  chance  of  healing. 
These  bones,  recalling  those  seen  in  long-standing 
osteomyelitis,  are  sometimes  found  after  being  gouged 
out  to  enclose  a  metallic  fragment  in  the  centre  of  the 
mass. 

(c)  The  periosteum  is  more  resistant  to  infection  than 
the  bone-marrow.  A  small  part  of  it  at  the  ends  of 
the  shaft  undergoes  necrosis,  baring  the  ends  of  bone 
in  the  wound.  This  is  of  no  great  importance  unless 
the  marrow  is  also  destroyed,  but  should  it  be  so, 
the  periosteal  infection  facilitates  the  formation  of  the 
ring  sequestrum  of  medullary  origin  described  above. 

As  a  rule  the  infection  which  destroys  the  marrow- 
cells  stimulates  periosteal  activity.  But  the  normal 
physiological  activity  of  the  bone-forming  tissue  is 
disorganised,  and  large  masses  of  unhealthy  bone  are 
formed  ;  the  normal  position  of  the  active  periosteum 
being  upset  by  splintering,  it  forms  a  misshapen 
callus,  which,  as  we  have  seen,  frequently  surrounds 
a  totally  empty  medullary  cavity.  This  is  the  true 
classical  external  callus  abnormally  developed. 
Nothing  will  replace  it,  since  no  ossification  from 
within  {i.e.  from  the  marrow)  is  possible.  Hence  the 
appearance  of  all  the  large  calluses— multilocular 
with  a  central  cavity — -which  are  so  frequently  seen. 
Inside  this  cavity  there  are  soft  granulations,  some- 
times fragments  of  metal,  often  a  bell-sha])ed  seques- 
trum which  is  merely  a  splinter  pushed  into  the 
medullary  canal  at  the  time  of  the  injury,  which 
suppuration  has  not  been  able  to  eliminate.  Later 
on  there  are  sequestra  produced  by  osteitis  from  the 
ends  of  the  shaft. 


306 


TREATMENT   OF   FRACTURES 


Briefly  in  these  cases  sepsis  results  in  destruction 
of  the  marrow  and  disease  of  the  periosteum  the 
effects  of  which  it  will  be  very  difficult  to  remedy  later. 

Sometimes  a  severer  or  more  lasting  infection  suc- 
ceeds in  inhibiting  all  activity  of  the  periosteal  bone- 


FiG.  10. — Typical  nAeduilaiy 
cavity  witli  a  large  periosteal 
callus  after  imion  of  a  shell- 
fragment  fracture  which  had  not 
been  cleared  by  operation.  The 
sinus  persisted  for  sixteen 
months,  altliough  scraped  clear 
on  three  occasions.  The  case 
was  cured  by  esquillectomy  with 
levelling  of  the  bony  walls. 


[g 

V 

Bp^^ca 

'4 

n 

C 

^9 

m 

f  Bbl 

i'^BSk 

i^^^HBr 

mH^^HF 

^y^mB^^B^S 

•'\^     ^^^^ffiH^B 

%kwSK^^^^L 

*^^^^H 

^^E 

^mSSm 

Fig.  U. — Multilocular  and 
multilist ular  callus  (with  four 
centres  of  suppuration)  photo- 
graphed after  seven  montlis' 
suppuration.  All  the  sphnters 
had  been  deliberately  left  to  aid 
bone-formation.  Resection  of 
tlie  callus  foUovved  by  osteo- 
synthesis gave  good  results,  but 
marked  shortening. 


forming  tissue,  just  as  it  has  destroyed  that  of  the 
marrow ;  after  the  spontaneous  elimination  of  sequestra, 
nothing   is   left    between    the   rarefied  and    atrophied 


GENERAL  STUDY  OF  SHAFT  FRACTURES     307 


ends  of  the  shaft  but  soft  tissue  of  no  definite  struc- 
ture. The  death  of  the  osteogenetic  cells,  without 
any  interposition  of  muscle  between  the  bone  ends 
or  without  esquillectomy,  eventually  produces  a 
definite  pseudarthrosis  which  is  extremely  difficult  to 


Fig.  12. — Callus  with  a  large 
cavity  beneath  the  periosteal 
bone,  in  which  are  recurring  se- 
questra caused  by  osteitis  of  the 
shaft.  The  case,  in  which  sub- 
periosteal esquillectomy  had  not 
been  practised,  recovered  at  the 
end  of  eighteen  months  after 
six  operations  with  ankylosis  of 
the  shoulder  due  to  suppura- 
tive arthritis. 


Fig.  13. — Spontaneous  pseud- 
arthrosis after  profuse  sup- 
puration and  the  elimination 
of  many  sequestra.  No  opera- 
tion on  the  bone  had  been  per- 
formed. Cure  was  obtained  by 
metalUc  osteo- synthesis .  The 
persistence  of  displaced  seques- 
tra will  be  noticed  in  this  pho- 
tograph. , 


cure,  since  all  power  of  local  bone-formation  is  lost. 
Numerous  examples  are  seen  in  all  the  long  bones 
except  the  femur.  Almost  all  the  false  joints  ^pon 
which  I  have  operated  were  caused  in  this  way. 


308  TREATMENT    OF    FRACTURES 

To  recapitulate, — injection  is  fatal  to  the  vitality  of 
hone-jragwents  and  hone-forming  tissue  ;  it  destroys 
the  viarrow,  and  inhibits  or  seriously  interferes  with 
periosteal  activity ;  it  jrroduces  misshapen  callus, 
osteomyelitis,  and  pseudarthrosis .  It  is  to  he  feared 
ahove  everything  else. 

Besides  these  deplorable  local  effects,  infection  pro- 
duces effects  equally  serious  in  the  bone  itself  at  some 
distance  from  the  fracture,  owing  to  the  frequent 
existence  of  fissures. 

These  fissures,  unimportant  in  an  aseptic  or  im- 
mediately disinfected  wound,  seriously  affect  the  prog- 
nosis should  any  suppuration  set  in.  The  infection 
spreads  along  the  fissures  to  a  great  distance  from  the 
fracture,  inducing  ditluse  osteomyelitis  of  the  shaft 
or  sub-chondral  articulai'  osteitis  which  soon  affects 
the  joint  and  results  in  serious  infection  of  the  latter. 
Jn  this  Avay  suppurative  arthritis  appears  after  about 
ten  days  in  cases  of  sub-ei)ii)hyseal  fracture  of  the 
u])per  part  of  the  humerus,  or  suppurative  arthritis 
of  the  knee-joint  after  supra-condylar  fracture  of  the 
femur  ;  this  arthritis  necessitates  secondary  amputa- 
tions which  are  not  alw.ays  successful  in  saving  life. 

Some  of  these  fissures  are  visible  under  X-rays, 
but  more  usually  they  are  not  distinguishable  in  the 
negative,  particularly  in  the  epiphyses.  Some  quite 
extensive  fissures  are  im2)erceptible  on  direct  examina- 
tion, and  are  only  recognised  in  a  transverse  section  of 
the  bone.  This  explains  the  possibilit}^  of  late  secon- 
dary arthritis  after  the  ankle  has  been  brought  to  a 
right  angle  under  an  anaesthetic,  for  instance.  In  any 
case,  the  frequency  of  these  giave  com])lications  ne- 
cessitates thorough  operative  disinfection  of  the  main 
fractured  area  if  they  are  to  be  avoided. 

Infection  may  reach  joints  in  other  ways  :  in  very 
virulent  infections,  when  no  fissures  exist,  suppurative 
arthritis  sometimes  develops  rapidly  ;  the  medullary 
canal  is  full  of  pus  ;   a  widespread  diffuse  osteomyelitis 


GENERAL  STUDr  OF  SHAFT  FRACTURES    309 

has  supervened,  and  the  prognosis  is  extremely  grave. 
In  section  one  can  clearly  see  the  track  along  which 
infection  has  spi-ead  through  the  cancellous  tissue, 
generally  from  a  splinter  within  the  canal. 

Spread  of  infection  may  also  occur  along  the  compact 
bone  beneath  the  periosteum,  but  this  is  much  less 
common. 

Infection  is  not  merely  dangerous  to  bone  elements ; 
persistent  suppuration  has  serious  effects  on  the  sur- 
rounding soft  tissues.  Tracks  of  pus  develop  along 
muscles,  infiltrate  muscular  sheaths,  necrose  tendons 
and  fascise,  and  often  find  outlet  at  a  great  distance 
from  the  wound.  Sclerosis  of  muscles  and  thickening 
of  fasciae  follow,  the  final  result  always  being  marked 
diminution  of  the  functional  value  of  the  limb.  This 
is  particularly  deplorable  in  the  neighbourhood  of 
joints,  as  stiffness  follows,  with  ligamentous  shortening 
which  it  is  difficult  to  remedy  later. 

When  suppuration  is  set  ujd  in  the  neighbourhood 
of  large  vessels,  it  is  not  a  question  of  remote  risk,  but 
immediate  serious  complications  may  occur.  Vessels 
are  undoubtedly  very  resistant  to  suppuration  round 
them.  It  is  commonly  believed  that  arteries  may  be 
found  crossing  a  large  jDurulent  area  like  a  cord,  and 
remaining  intact.  But  this  can  only  occur  if  an  artery 
is  absolutely  healthy.  If  the  projectile  in  passing,  or 
any  splinters  which  it  has  scattered,  happen  to  injure 
the  artery,  sudden  secondary  haemorrhage  may  occur 
later.  The  bruised  patch,  which  would  have  healed 
easily  in  aseptic  surroundings,  gradually  undergoes 
necrosis,  and  this  ulcerated  patch  is  suddenly  forced 
out,  causing  violent  haemorrhage.  The  presence  of 
splinters  in  contact  with  a  vessel,  as  seen  notably  in 
the  thigh,  facilitates  the  occurrence  of  this  complica- 
tion. 

Sepsis  has  little  effect  on  nerves,  unless  they  are 
involved  in  the  original  injury.  But  as  in  the  case  of 
arteries,  if  a  nerve  has  once  been  crushed  or  severed, 


310 


TREATMENT   OF   FRACTURES 


and  its  two  ends  are  in  contact  with  a  purulent  area 
for  a  considerable  length  of  time,  healing  of  the  injury 
is  an  extremely  difficult  matter.  Hard  and  dense  tissue 
forms  round  it  which  prevents  spontaneous  regenera- 
tion a,nd  greatly  impedes  surgical  interference. 

2.  Faulty    Union   (anatomical   and  physiological). — 
Consolidation    may    be    seriously    impeded   or    even 

actually  arrested  by  cer- 
tain anatomical  causes, 
the  persistence  of  which 
usually  results  in  a 
vicious  union. 

War  fractures  un- 
doubtedly undergo  less 
marked  displacement 
than  those  seen  in  civil 
life,  since  the  lacerated 
muscles  pull  less  strongly 
on  the  fragments,  but 
there  are  certain  con- 
stant displacements 
where  non-reduction 
entails  serious  results . 
Persistent  infection  with 
suppuration  in  the  region 
of  the  fracture  render 
the  latter  liable  to  in- 
complete reduction,  both 
at  first  because  oedema 
and  swelling  of  the  injured  limb  prevent  its  being 
set  easily,  and  later  because  the  frequent  dressing 
of  it  for  months  necessitated  by  suppuration,  render 
it  difficult  to  maintain  absolute  immobility. 

Callus  formation  is  hindered  by  antero-yosterior  dis- 
placement :  thus  in  certain  fractures  of  the  thigh,  the 
upper  fragment  tends  to  tilt  forwards,  while  the  lower 
is  pulled  backwards  :  without  referring  to  the  various 
effects    of    muscular  action  in  such   cases,  it  will  be 


^????J?>'^ 

m0mmm 

^ 

'^  \ 

/M 

\ 

|b 

■  H 

"'■-..., 

m 

Fig.  14. — Pseudarthrosis  of  the 
humerus  due  to  failirre  in  re- 
duction. 


GENERAL  STUDY  OF  SHAFT  FRACTURES    311 


obvious  that    the  formation   of   a   callus   is  scarcely 
encouraged  by  the  persistence  of  wide  separation. 

Longitudinal  displacement  or  over-riding  is  a  still 
more  awkward  matter  ;  it  is  particularly  freijuent  in 
the  thigh  and  arm.  Unless  it  is  reduced,  union  can 
only  occur  by  the  formation  of  a  lateral  periosteal 
bridge,  producing  a  bayonet-shaped  callus  which  alters 
the  axis  of  the 
limb  and  leads  to 
marked  shorten- 
ing. 

Lateral  displace- 
ment occurs  par- 
ticularly in  the 
neighbourhood  of 
epiphyses  and  in 
fractures  near 
joints,  frequently 
giving  rise  to 
p  s  e  u  d  a  r  throsis, 
notably  in  the 
h  umerus  and 
femur:  at  the 
shoulder  and  in 
the  sub  -  trochan- 
teric region,  the 
upper  fragment  is 
maintained  in  a 
position  of  marked 
abduction  by  the 
external  rotators 
inserted  in  it  (connecting  the  scapula  and  tuberosities 
in  one  case,  and  the  pelvis  and  the  trochanter  in 
the  other),  while  the  lower  fragment  is  pulled  inwards 
and  upwards  by  the  adductors  and  internal  rotators  ; 
approximation  of  the  two  fragments  is  impossible. 
It  is  absolutely  essential  for  satisfactory  consolidation 
to  bring  the  lower  fragment,  the  only  movable  of  the 


Fig.   15. — Pseudarthrosis  of  the  femur 
due  to  failure  in  reduction. 


312  TREATMENT    OF    FRACTURES 

two,  into  line  with  the  other  ;  unless  this  precaution 
is  taken,  pseudarthrosis  is  favoured,  and  if  union 
occurs,  it  does  so  in  a  faulty  position  which  interferes 
with  the  functions  of  the  limb. 

Displacement  by  rotation  is  possible  in  all  bones,  but 
it  is  most  frequent  and  serious  in  the  forearm.  The 
upper  fragment  assumes  a  position  of  supination 
under  the  action  of  the  biceps  and  supinator  brevis, 
while  the  lower  is  fixed  in  pronation  by  gravity 
and  the  pronator  quadratus.  Thenceforward,  to  use 
the  expression  brought  into  general  use  by  Destot,  the 
bones  are  "  decales  "  (deprived  of  support),  and  the 
physiology  of  the  hand  movements  is  seriously  inter- 
fered with. 

Displacement  in  the  line  of  the  hone  causes  angulation 
of  the  fragments,  and  may  occur  everywhere,  but 
particularly  in  the  forearm  and  the  leg  ;  the  V-shaped 
consolidation  which  results  is  particularly  unsound, 
and,  in  the  lower  limb  perhaps  more  than  elsewhere, 
gives  rise  to  marked  deformity. 

In  brief,  the  various  displacements  possible  in  a 
fracture  result  in  interfering  with  the  formation  of  the 
callus  by  sejjarating  the  fragments,  or  by  allowing  one 
to  form  in  a  faulty  position  which  will  deprive  the  limb 
of  a  large  part  of  its  functional  value. 

Correct  treatment  does  not  consist  only  in  the 
maintenance  of  asepsis  :  no  fracttire  is  really  cured 
unless  the  fragments  are  united  by  a  healthy  callus  in 
line  ivith  the  normal  axis  of  the  shaft,  so  that  forces  act- 
ing on  the  arm  of  the  lever  may  be  exercised  normally 
and  have  a  normal  physiological  actio7i. 

Treatment  which  is  intended  to  restore  normal  con- 
ditions should  be  directed  towards  this  object. 


CHAPTER    XI 

GENERAL    PRINCIPLES    IN    THE    CONSERVATIVE 
TREATMENT    OF   FRACTURES 

For  reasons  already  outlined,  it  follows  that  in  modern 
war  fractures,  other  than  those  by  bullets  with  puncti- 
form  wounds,*  treatment  to  reproduce  original  con- 
ditions must  involve  three  essential  features  :  dis- 
infection, reduction,  and  immobilisation,  which  are 
necessary  for  the  production  of  regular  union  in  a 
straight  line  by  a  healthy  callus. 

But  the  order  in  which  these  three  parts  of  the 
treatment  are  taken  in  hand  is  not  a  matter  of  indiffer- 
ence :  it  has  often  been  said  during  the  present  war 
that  reduction  and  immobilisation  are  the  main  points 
in  treatment,  and  if  well  realised,  by  reducing  the  in- 
tensity of  infection  and  the  difficulty  of  treating  it, 
limit  the  scope  ot  the  operation  required,  thereby  re- 
ducing this  to  the  category  of  a  secondary  intervention. 

In  my  opinion  this  is  a  serious  clinical  mistake  :  un- 
doubtedly immobilisation  is  at  the  root  of  all  treatment 
directed  against  inflammation,  and  sepsis  developing 
in  a  fracture  is  certainly  more  serious  if  the  fracture  is 
badly  reduced  or  not  immobilised.  But  this  is  only 
one  side  of  the  question  of  the  causation  and  treat- 
ment of  infection  in  war  :  the  most  complete  immo- 
bility in  the  world  and  the  speediest  reduction  will 
not  prevent  the  development  of  gas  gangrene  if  the 
wound  is  not  suitably  opened  up,  nor  will  it  prevent 
the  appearance  of  acute  osteomyelitis,  connected  with 

*  I  repeat  that  extensive  crushing  justifying  amputation  is  not 
discussed  here. 

313 


314  TREATMENT    OF    FRACTURES 

the  presence  of  infected  clothing  and  debris  in  the 
medullary  canal. 

In  regarding  immobilisation  as  the  salient  point  in 
treating  fractures  caused  by  shell-fragments,  a  great 
risk  is  run  for  which  nothing  can  compensate  :  no 
reliance  should  be  placed  on  stereotyped  formulae  ;  it 
should  be  realised  that  the  essential  and  fundamental 
process  in  the  treatment  of  all  fractures,  on  which  depend 
the  patient's  future,  at  first  his  life,  subsequently  the 
safety  of  his  limb,  and  ultimately  its  functioning  power, 
is  early  and  immediate  cleansing  :  every  fracture,  apart 
from  the  exceptions  above-mentioned,  should  he  so 
treated,  as  early  as  possible,  that  its  subsequent  course 
may  be  aseptic,  in  order  that  no  infection  may  inhibit 
the  bone-forming  tissues  which  effect  repair. 

The  other  elements  of  the  treatment  should  follow 
this  and  not  precede  it  :  their  proper  function  is  to 
control  the  formation  of  callus,  and  to  ensure  that 
union  follows  in  a  straight  line  :  they  are  the  easier 
to  carry  out  the  more  regular  the  progress  of  the 
wound,  that  is,  the  earlier,  more  careful  and  complete 
the  operative  cleaning  which  has  been  practised.  Re- 
duction and  immobilisation  are  only  supplementary  to 
the  operation  ;  they  should  follow,  and  not  precede  it. 

With  this  in  view,  I  shall  discuss  : — 

1.  The  disinfection  of  fractures  by  operation. 

2.  Reduction. 

3.  Immobilisation. 

I.   Operative  Disinfection  of  Open  Fractures'*' 

This  should  be  considered  in  two  categories  : — 
In  (a)  the  wound  is   seen  in  the  first  few  hours, f 
previous  to  any  clinical  sign  of  infection. 

*  I  use  this  term  once  more  to  exclude  bullet  fractiu-es  with 
punctiform  skin  wounds,  which  should  be  classed,  as  I  have  said, 
as  simple  fractures. 

+  Theoretically  this  means  in  the  first  twelve  hours  ;  practically, 
\n  the  first  twenty-four. 


GENERAL  PRINCIPLES  IN  TREATMENT    315 

In  (6)  the  wound  is  seen  after  the  appearance  of 
symptoms  of  infection. 

A.  Initial  operative  disinfection  of  fractures  in  the  first 
few  hours  :   exploratory  and  prophylactic  esquillectomy. 

1.  The  Prestciple. — Like  ail  wai-wounds,  fractures 
should  be  treated  by  operation  as  speedily  as  possible, 
in  order  to  ensure  complete  prevention,  at  the  outset, 
of  any  acute  or  chronic  infection  which  threatens  the 
injured  region.  There  being  no  means  in  the  earliest 
stages  of  distinguishing  seriously  infected  from  only 
slightly  infected  fractures,  all  should  receive  the  same 
preventive  treatment  without  distinction. 

This  principle  of  general  disinfective  action  is  at  the 
root  of  all  prophylaxis. 

It  is  essential,  therefore,  in  any  individual  case,  as 
in  all  wounds  of  war,  at  once,  even  if  not  the  slightest 
sign  of  infection  has  appeared,  to  remove  any  foreign 
bodies  in  the  wound,  scraps  of  clothing,  tissue  de- 
stroyed by  the  injury  or  liable  to  necrosis  following 
infection  :  the  wound  after  such  treatment  should  be 
clean,  containing  no  suspicious  elements  or  recesses 
where  infection  may  develop.  Everything  contused 
or  lacerated  should  be  exposed  thoroughly. 

The  operation  required  is  not  a  mere  matter  of  drain- 
age {e.g.  widening  the  entry  and  exit  wounds  to  intro- 
duce drainage  tubes,  after  a  rough  cleaning  of  the 
soft  parts),  nor  should  it  he  limited  to  partial  and  pru- 
dent removal  of  a  few  isolated  fragments  dictated  by  a 
gronjidless  fear  of  pseudarthrosis  ;  still  less  should  it  he  a 
rapid  and  indiscriminate  scraping  of  the  fractured  area, 
bringing  out  everything  that  the  instrument  encounters 
ns  it  is  withdrawn. 

The  danger  lies  in  the  medullary  canal. 

This  particularly  should  he  laid  widely  open  by  a 
methodical  operation  consistent  with  the  main  princip)les 
of    preventive  disinfection  of  war-wounds,  alloiving  of 


316  TREATMENT    OF   FRACTURES 

complete  exploration  of  the  area,  and  of  any  necessary 
excisions. 

With  this  object,  the  operation  should  be  conducted  in 
the  following  way,  under  a  general  ancesthetic  and  after 
radiography  if  possible,  for  the  ideal  is  to  approach  the 
fracture  with  an  exact  knowledge  of  its  structural  details. 

A  lofig  and  carefully  placed  incision  is  tnade,  to  facili- 
tate, first,  the  removal  with  bistoury  and  forceps  of  any 
soft  tissues  which  are  contused  or  crushed  ;  a  search  is 
then  made  for  foreign  bodies  :  in  brief,  nothing  should 
be  left  in  the  region  of  the  fracture  which  will  infect  it  or 
encourage  infection  to  develop. 

This  done,  all  free  splinters  which  have  been  forced 
into  muscles  must  be  removed  with  great  care.  Patient 
and  minute  starch  is  required,  not  a  hasty  clearance. 
Next,  the  region  of  adherent  splinters  is  approached ,  and 
such  are  removed  as  appear  to  interfere  with  exploration 
and  thorough  display  of  the  medullary  cavity. 

At  the  end  of  the  operation  the  medullary  cavity 
should  present  roughly  the  appearance  of  a  groove  in 
cases  of  fractures  with  large  splinters,  a  funnel  in  frac- 
tures with  one  large  short  splinter,  and  entire  loss  of 
substance  in  a  many-splintered  fracture.  In  the  un- 
usual event  of  a  transverse  fracture,  where  there  are 
no  splinters,  about  J  inch  should  be  resected  from  each 
end  of  the  shaft,  as  the  latter  are  contused  and  devita- 
lised by  the  violence  of  impact. 

Nothing,  in  fact,  about  which  there  is  any  suspicion, 
nothing  which  can  favour  infection,  should  be  left  in 
the  neighbourhood  of  the  fracture,  so  that  infection 
may  not  interfere  with  union,  bv  causing  necrosis  of  the 
osteogenetic  elements  in  the  marrow  and  periosteum. 

2.  AcAfANTAGES. — This  wide  esquillectomy,  the  sole 
7neans  of  obtaining  a  detailed  kjwwledge  of  the  injury,  is 
a  preventive  step,  since  it  removes  all  unkyiown  factors 
from  the  wound. 

(a)  It  absolutely  prevents  the  developynent  and  conse- 


GENERAL  PRINCIPLES  IN  TREATMENT    317 

quences  of  serious  sepsis. — If  these  appear  it  means 
that  the  operation  was  badly  or  only  partially  done. 
No  proof  of  this  is  needed  beyond  the  fact  that  the 
operation  is  intended  to  remove  anything  calculated  to 
produce  sepsis  or  to  favour  its  development. 

All  who  have  performed   this  operation  are  unani- 
mous in  declaring  that  it  has  enabled  them  to  avoid 
gas  gangrene   and  acute   osteomyelitis  ;    others  who 
first  criticised  it  have  ultimately  declared  in  its  favour. 
For  my  own  part,  I  have  practised  it  systematically 
since  the  month  of  August    1914,  according    to  the 
princiijles  and  methods  of  my  teacher,  Poncet.     I  am 
doing  practically  the  same  now  as  I  have  done  from 
the  beginning,  without  introducing  any  new  feature. 
In  this  way  I  have  been  able  to  cure  more  than  250 
comminuted  shaft  fractures  with  the  loss  of  only  one 
case,  without  a  single  case  of  gas  gangrene?  and  with 
only  one  case  (which  proved  fatal)  in  which  persistent 
sepsis  necessitated  amputation.* 

Supplementary  proof  is  easy :  at  the  front  the 
surgeon  has  only  to  reckon  the  number  of  his  secondary 
amputations  for  fracture  ;  at  the  base  he  has  merely 
to  question  these  men,  and  he  will  find  that  the 
majority  of  these  amputations  were  necessitated  by 
fracture,  and  that  in  almost  every  case  the  amputa- 
tion was  secondary. 

Jt  may  be  said  that,  in  an  ambulance  unit  at  the 
front,  the  number  of  secondary  amputations  is  in- 
versely proportional  to  the  number  and  extent  of  early 
esquillectomy  operations. 

Further,  if  need  be,  the  question  can  be  decided  by 
studying  the  development  of  each  surgeon's  personal 
views  ;  the  number  favouring  this  operation  on  prin- 
ciple has  become  considerable,  and  each  recommends 
a  more  and  more  comprehensive  operation.  At  first, 
in  August  1914  and  early  in  1915,  we  were  very  few 

*  Esquillectomy  was  performed  on  the  third  day  after  sepsis  had 
fully  developed. 


318         TREATMENT    OF    FRACTURES 

and  very  much  criticised  ;  everything  that  I  have 
since  seen  and  done  has  shown  me  that  we  were  right. 

In  brief,  after  twenty-two  months  of  war,  it  must  be 
acknowledged  that  wide  and  early  esquillectomy  is  an 
absolute  protection  against  the  serious  infections  which 
endanger  the  life,  or  at  least  the  limb,  of  every  case  of 
fracture,  and  that  it  alone  will  give  this  result. 

(&)  But  that,  is  not  the  only  advantage  of  this 
method :  immediate  complete  esquillectomy,  by 
allowing  of  complete  investigation  of  the  wound,  also 
ensures  the  prevention  of  all  the  slight  chronic  infec- 
tions whose  secondary  effects  are  so  prone  to  prevent 
a  satisfactory  union  of  the  fractured  bones.  By  it  all 
foreign  bodies,  all  tissue  debris  condemned  to  necrosis, 
are  removed  at  once.  This  avoids  the  occurrence  of 
that  persistent  suppuration  which,  sometimes  destroy- 
ing marrow  and  periosteum,  leads  to  pseudarthrosis, 
sometimes,  by  irritating  the  periosteum  and  disturbing 
its  osteogenetic  activity,  eventually  produces  a  patho- 
logical callus,  within  which  infection  produces  necrosis 
of  the  ends  of  the  shaft  and  causes  persistent  osteitis. 

A  radical  esquillectomy  entirely  exposes  the  medul- 
lary canal,  which  is  often  filled  with  small  fragments 
and  metallic  or  other  particles ;  without  it,  these 
cannot  be  removed,  and  osteomyelitis  is  certain ; 
sometimes  it  is  acute,  sometimes  chronic  from  the 
beginning.  It  can  only  be  avoided  by  completely 
cleaning  the  area  of  destruction  in  the  shaft. 

In  the  large  number  of  shaft  fracture  cases  which 
I  followed  until  cure,  there  were  only  about  ten  in 
which  a  sinus  persisted.  This  always  occurred  in 
wounds  in  which  I  had  thought  it  well  to  leave  one  or 
two  fragments,  apparently  firmly  adherent  and  well 
supplied  with  blood;  in  these,  removal  of  the  frag- 
ments stopped  the  discharge.  There  were  very  few 
amongst  my  cases  in  which  a  late  abscess  developed 
(after  a  year  or  more),  whereas  this  is  usually  very 
frequent ;    the  two  or  three  which  I  have  seen  have 


GENERAL  PRINCIPLES  IN  TREATMENT  311) 

appeared  in  cases  upon  which  I  had  operated  too  late 
to  prevent  serious  sepsis.  Anyone  who  knows  the 
appalling  amount  of  osteitis,  osteomyelitis,  and  cases 
of  persistent  sinus  which  fill  our  military  hospitals  at 
the  present  time  will  not  for  a  moment  question  the 
enormous  advantage  of  avoiding  the  terrible  conse- 
quences of  early  infection. 

3.  Criticisms  of  this  Operation. — Free  prophy- 
lactic esquillectomy  is  not,  however,  practised  every- 
where. Many  surgeons  are  afraid  of  it,  and  assert 
that  it  predisposes  to  pseudarthrosis. 

{a)  It  is  useless,  they  say,  because  many  fractures  unite 
ivithout  such  immediate  operation  if  they  are  properly 
immobilised,  and  because,  if  it  prove  necessary,  a 
secondary  and  limited  esquillectomy,  not  interfering 
with  any  adherent  fragments,  is  almost  always 
sufficient.  Later,  if  necessary,  the  surgeon  is  free  to 
search  for  any  enclosed  sequestrum,  but  interference 
should  be  limited  to  this,  and  this  is  better  than  a 
flail-limb  after  removal  of  an  excessive  quantity  of 
bone. 

Thus  described  it  seems  natural,  and  even  wise,  to 
refrain.  But  is  this  a  true  statement  of  the  case  ? 
This  supposed  harmlessness  of  war-fractures  has 
scarcely  been  seen  except  at  the  bases,  where  the 
question  cannot  rightly  be  judged.  A  man  must  go 
to  the  front  to  appreciate  truly  the  seriousness  of 
fractures  by  shell-  or  bomb-fragments.  Now  even  at 
the  present  day,  after  twenty-two  months  of  war,  this 
is  what  is  to  be  seen  there  :  wherever  free  esquillec- 
tomy is  not  carried  out  early  and  systematically,  before 
any  clinical  sign  of  infection,  cases  of  gas  gangrene 
and  serious  osteomyelitis  have  still  to  be  battled  with  , 
there  are  deaths  from  sepsis,  and  early  secondary 
amputations  for  infected  fractures.  On  the  other 
hand,  where  esquillectomy  is  a  general  rule,  there  is 
no  gas  gangrene,  and  no  dangerous  sepsis  except  in 
cases  already  developing  it  on  arrival  ;    fracture  oases 


320         TREATMENT    OF    FRACTURES 

explored  early  run  an  aseptic  course,  and  no  secondary 
amputations  for  septic  fractures  are  performed. 

Early  free  esquillectomy  or  frequent  secondary 
amputations—  the  question  can  be  expressed  in  no 
other  way — and  it  is  this  fact  which  must  be  realised 
by  anyone  who  wishes  to  get  to  the  root  of  the  matter. 
In  the  base  hospitals  it  is  a  different  matter  :  un- 
operated  fractures  arriving  twenty-four  or  forty-eight 
hours  after  evacuation  are  more  often  caused  by 
bullet  wounds,  punctiform  at  entry  and  exit  (whose 
habitually  aseptic  course  everyone  knows),  or  by 
shrapnel  bullet  (whose  comparative  benignity  is  fre- 
quent). Unoperated  shell-fragment  cases  are  more 
and  more  rare,  for  the  simple  reason  that  surgeons  at 
the  front,  better  aware  of  the  serious  danger  which 
these  cases  run,  do  not  send  them  further  until  the 
initial  esquillectomy  has  been  performed. 

(6)  But,  it  will  be  said,  why  advocate  so  siveeping  an 
interference  ?  Why  not  limit  it  to  the  removal  of  free 
splinters,  leaving  those  which  are  adherent  and  living  ? 
Would  it  not  be  better  to  retain  everything  which 
appears  likely  to  live,  leaving  it  to  Nature  to  decide 
what  she  wishes  to  retain  and  what  to  reject  ? 

This  would  obviously  be  the  ideal  course  if  there 
were  not  certain  disadvantages  in  relying  so  much  on 
Nature.     These  disadvantages  are  the  following  : 

(i)  Serious  infection  cannot  be  prevented  except  by  a  com- 
plete clearance,  leaving  nothing  suspicious  in  the  wound, 
which  should  be  mechanically  disinfected  through- 
out. If  adherent  fragments  are  left  undisturbed,  how 
are  scraps  of  clothing  to  be  discovered,  caught  on  the 
points  of  the  shaft,  embedded  firmly  in  the  cancellous 
tissue  of  some  adherent  splinters  bordering  on  the 
track  of  the  missile  ?  How  are  those  isolated  splinters 
to  be  removed  which  have  penetrated  the  medullary 
canal,  and  are  about  to  undergo  necrosis  in  an  already 
injured  region,  thus  giving  rise  to  serious  osteomyelitis, 
sometimes  to  interminable  suppuration  ?     Wide  clear- 


GENERAL  PRINCIPLES  IN  TREATMENT    321 


ance  will  ensure  sufficient  exploration  of  the  fracture 
to  guarantee  satisfactory  development  and  repair. 

This  is  well  shown  by  what  is  found  in  the  wound 
during  a  second  operation  to  complete  an  originally 
insufficient  esquillectomy  ;  in  one 
in  three  cases  fragments  of  clothing 
are  still  found  enclosed  in  it  (see 
fig.  16). 

(ii)  Without  esquillectomy,  the 
prevention  of  chronic  iiijection  can- 
not he  depended  upon  (and  this 
certainty  is  essential)  ;  a  fracture 

Fig.  16. — Fracture  of  the  femiir  after 
incomplete  esquillectomy  at  the  front.  On 
the  eighth  day,  when  I  first  saw  the  case, 
suppuration  was  profuse.  I  removed  the 
large  remaining  fragment,  leaving  the 
periosteum,  thereby  discovering  and  re- 
moving a  shell-fragment  and  a  fetid  mass 
of  clothing  material  rammed  liigh  up  the 
medullary  canal,  which  could  not  have 
been  discovered  without  esquillectomy. 
This  was  sufficient  to  stop  the  suppuration; 
there  was  no  further  pyrexia,  and  on  the 
thirty-fifth  day  the  patient  could  raise  the 
thigh. 

not  entirely  cleaned  will  sup- 
purate ;  this  suppuration,  which 
is  almost  always  difficult  to  stop, 
will  produce  the  troublesome  effects 
described  above,  on  the  ends  of 
the  shaft  and  on  the  marrow  ; 
this  should  be  avoided  at  all  costs, 
for  anything  is  better  than  chronic 
ostemnyelitis  of  the  callus,  which 
may  persist  for  ariy  length  of  time.  Not  enough 
thought  is  given  to  the  life  which  those  suffering 
from  osteomyelitis  are  fated  to  lead  in  the  future, 
with  continued  pain,  sinuses  constantly  reappearing, 
necessitating  repeated  operations   whicli   they   must 


TREATMENT    OF    FRACTURES 


undergo  witliout  evei'  knowing  how  far  away  is  tlie 
])romi!<e(l  cure,  or  whether  amputation  will  not  even- 
tually be  necessary.  Surely  it  is  worth  while  to  take 
any  trouble  that  will  spve  this  long 
maj'tyrdom. 

This  can  easily  be  done  without 
endangering  the  future  solidity  of 
the  bone. 

Esquillectomy,  which  protects 
from  everything  giving  rise  to 
disease  of  the  callus,  if  properly 
carried  out,  should  leave  in  the 
wound  thus  disinfected  by  me- 
chanical means  all  the  elements 
necessary  for  speedy  union. 

(c)  It  is  also  true  that  certain  sur- 
geons have  criticised  the  viethod  by 
stating  that  it  predisjioses  to  pseudar- 
throsis,  but  their  opinion  scarcely 
deserves  credit.  With  no  ex[)e- 
rience  of  surgery  at  the  fi'ont,  they 
have  been  appalled  by  certain  very 
extensive  removals  of  bone  prac- 
tised there,  in  some  cases  by  the 
careless  and  ignorant,  in  otheis  by 
more  experienced  surgeons  who  re- 
fused to  amputate  an  arm  for  enor- 
mous injuries  when  the  nerves  and 
vessels  were  intact. 

Ordinary  cases  are  different,  and 
we  may  once  and  for  all  dismi>s 
that  dread  of  pseudarthrosis  which  has  so  often  |)j'c- 
vented  necessary  steps  from  being  taken  ;  disregarding 
deliberate  removal  of  bone  to  avoid  disarticulation  oj- 
amputation,  which  should  not  be  considered  in  this 
connection,  it  may  be  stated  dogmatically  that  pseud- 
arthrosis seen  in  base  hospitals  is  almost  always  the  re- 
sult of  prolonged  sepsis,  and  not  of  too  free  an  esquillectomy. 


Fi«.  17. — Radio- 
graph showing  the 
presence  of  frag- 
irienli  iu  the  medul- 
lary canal;  the 
wound  had  sup- 
purated at  the  front 
for  two  niontlis,  and 
amputation  liacl  to 
be  performed. 


GENERAL  PRINCIPLED  IN  TREATMENT    323 

Speaking  practically  and  theoretically,  pseudarthro- 
sis,  in  the  cases  studied  here,  where  the  interposition 
of  muscle  is  extremely  rare,  can  only  point  to  one  of 
two  equally  bad  and  equally  avoidable  things — a  mere 
partial  esquillectomy,  allowing  of  an  infection  which 
destroyed  the  bone-forming  elements  in  the  region,  or 
a  technically  faulty  clearance,  which  did  not  leave 
the  latter  in  place  in  the  wound  which  it  had  cleaned. 

Now,  free  e-squillectomy  does  not  mean  technically 
faulty  esquillectomy.  The  only  technically  faulty  one 
is  that  which,  backed  by  no  physiological  idea,  tears 
away  the  fragments  which  are  to  be  removed,  careless 
of  leaving  in  the  wound  the  fertile  tissue  of  the  bone 
which  alone  assures  the  formation  of  a  regular  callus. 

This  fertile  tissue  is  found  only  between  the  fibrous 
layer  of  the  periosteum  and  the  shaft.  Oilier  conclu- 
sively proved  its  osteogenetic  value  ;  by  its  action 
the  periosteum  manufactures  bone,  with  equal  ease 
whether  it  be  young,  or  irritated  by  injury  or  slight 
infection  ;  but  to  leave  it  in  the  wound,  a  sharp 
rugine  must  be  used  to  separate  it  from  the  dense 
bone  to  which  it  adheres  ;   this  is  essential . 

All  surgeons  who  have  experimented  under  the  same 
conditions  as  Oilier,  all  those  who,  like  him,  have 
understood,  and  searched  in  the  periosteum  beneath 
the  fibrous  layer  for  the  deeper  osteogenetically  active 
layer,  have  got  the  experimental  and  clinical  results 
which  he  described. 

Hence  it  should  theoretically  be  admitted  that 
thorough  sub-periosteal  esquillectomy  with  a  sharj) 
rugine  leaves  in  ])lace  the  bone-forming  elements  which 
should  be  sufficient  to  re-establish  continuity  of  the 
bone. 

It  is  so  in  j)ractice  ;  surgeons  taught  to  respect  the 
periosteum  have  obtained  results  during  the  present 
war  which  are  the  best  experimental  and  clinical  })roof 
of  Ollier's  theories  that  could  be  adduced.  It  is 
thus  proved  that  the  only  operation  justitiable  is  one 


324  TREATMENT    OF    FRACTURES 

which,  preserves  in  the  wound  the  fertile,  as  well  as  the 
fibrous,  periosteum. 

A  weli-executecl  esquillectomy  is  not  simply  one 
which  checks  infection  ;  it  is  actually  and  only  that 
which,  taking  the  necessary  preventive  steps,  leaves  in 
the  wound,  undisturbed  by  any  pernicious  infection, 
the  periosteal  bone-forming  elements  which  will  even- 
tually form  a  regular  callus  ;  only  a  thoroughly  sub- 
periosteal esquillectoiny  is  justified. 

The  question  is,  then,  a  simple  one  :  esquillectomy 
followed  by  pseudarthrosis  is  a  badly  executed  esquil- 
lectomy. Early  sub- periosteal  removal  of  fragments 
under  ordinary  operative  conditions  does  not  expose  the 
fracture  to  the  danger  of  pseudarthrosis,  and  such  an 
operation  is  conducive  to  rapid  recovery  and  is  physio- 
logically  J2istified. 

Further,  it  should  be  understood  that  the  original 
esquillectoiny  is  not  a  resection  of  the  entire  circum- 
ference of  the  bone  ;  it  is  not  even  a  total  esquillectomy. 
'J'he  object  of  clearance  at  this  stage  is  to  dis})lay 
the  area  clearly  and  to  remove  everything  which 
interferes  with  complete  exploration  of  the  injuiy  and 
with  drainage.  In  more  than  two-thirds  of  cases  the 
operation  ultimately  leaves  the  ends  of  the  shaft  in 
contact,  thinned  down  but  forming  an  almost  con- 
tinuous trunk,  without  reducing  the  total  length  of  the 
bone. 

In  large-splintered  fractures  it  is  indeed  sufficient 
to  remove  the  principal  fragment  obscuring  the  medul- 
lary cavity.  After  the  operation  the  continuity  of  the 
bone  is  hardly  interrupted.  Anyone  doubting  this 
has  only  to  think  of  the  classical  description  of  the 
"  butterfly  wing  "  fracture,  which  is  equivalent  to  this 
ty})e  ;  removal  of  the  lateral  fragments  leaves  the 
extremities  of  the  shaft  intact,  and  meeting  at  the  point 
of  impact  of  the  missile. 

In  fiactures  with  one  large  and  short  splinter,  it  is 
enough  to  remove  this,  detached  as  it  is  and  wedged 


GENERAL  PRINCIPLES  IN  TREATMENT      325 


between  the  ends  of  the  shaft,  and  still  adherent  to 
muscles,  together  with  any  smaller  fragments  of  it 
which  are  already  dead ;  when  the  clearance  is  complete, 
the  shaft  has  lost  nothing  in  length,  but  is  only  deeply 
notched. 

Jn  fact,  in  at  least  two-thirds  of  the  cases,  free  esquillec- 
tomy  reduces  the  thickness  and  not  the  length  of  the  hone. 

This  being  the  case,  it  is  illogical  to  hesitate  at  esquil- 
lectomy  ;    the  anatomical  arrangement  of  the  ends  of 


X" 


•0 


Figs.  18,  19,  and  20. — ^Diagram  showing  what  is  left  by  esquil- 
lectomy  adapted  to  the  lesions  in  different  types  of  fracture. 
Compare  figs.  1,  2,  3,  and  4. 

the  shaft  is  such  that  consolidation  is  possible  even 
after  an  esquillectomy  almost  regardless  of  the  perios- 
teum, and  cannot  fail  after  an  entirely  sub-periosteal 
operation. 

There  remains  the  case  of  shattering  into  srnall 
splinters  :  if  the  shaft  is  shattered  in  its  entire  circum- 
ference, clearance  is  necessarily  total,  since  scarcely 
any  of  the  splinters  are  adherent.  In  theory,  there 
is  some  fear  of  a  false  joint,  but  if  great  care  is  exer- 
cised in  preserving  scraps  of  periosteum,  if  the  very 


326  TREATMENT    OF    FRACTURES 

natural  desire  to  remove  more  or  less  adherent  frag- 
ments by  a  sharp  twist  or  violent  pull  is  resisted,  if 
any  remaining  periosteum  is  carefully  removed  from 
free  splinters  with  a  rugine  (such  splinters  being  found 
on  the  outskirts  of  the  fracture),  a  kind  of  periosteal 
sheath  remains — -lacerated,  no  doubt,  but  sufficient  in 
its  length  to  ensure  the  formation  of  a  regular  callus. 

Here  the  process  is  decidedly  longer  than  in  the 
preceding  cases,  but  it  is  equally  sure  and  reliable  ; 
the  callus  which  results  is  equally  solid,  particularly  if 
no  attempt  is  made  entirely  to  prevent  shortening  by 
applying  too  powerful  an  extension. 

Although  in  the  former  cases  (the  large,  long-splin- 
tered type  and  that  with  one  large  short  splinter)  I 
have  seen  firm  union  occur  sometimes  in  30  days  in 
the  forearm,  in  35  in  the  humerus,  in  42  in  the  leg, 
and  in  45  in  the  thigh,  2  or  3  months  elapse  when  there 
is  extensive  shattering:  it  besjins  slowly  towards  the 
35th  day  by  the  formation  of  a  fibrous,  slightly  elastic 
and  flexible  mass  which  gradually  hardens,  generally 
on  one  side  at  first,  and  eventually  becomes  a  solid 
and  regular  callus.  Often,  moreover,  the  missile  not 
having  struck  the  shaft  squarely,  the  blow  was  more 
or  less  glancing,  and,  after  removal  of  small  splinters, 
a  projecting  piece  of  the  shaft  remains. 

All  possible  criticism  of  removal  of  fragments  is 
negatived  by  the  arguments  I  have  reiterated  here. 

But  esquillectomy  has  another  very  great  advan- 
tage to  which  attention  has  never  been  drawn,  and 
which  is  of  great  interest :  it  is  the  only  sure  means 
we  possess  of  moulding  the  callus  at  ivill  in  the  right 
direction.  When  numbers  of  splinters  are  left  on  the 
borders  of  the  area  there  is  a  temptation  to  use  them 
as  supporting  arches  for  ossification.  If  they  happen 
to  remain,  bone-formation  begins  around  them — tliat 
is  to  say,  to  some  extent  along  a  different  axis  from 
that  of  the  bone  itself  ;  the  callus,  from  the  way  in 
which   it   is  formed,  will  be  shapeless,  irregular,  and 


GENEBAL  PRINCIPLES  IN  TREATMENT    3-.>7 


redundant ;  sometimes  it  will  enclose  fragments  of 
muscle,  and  I  have  twice  seen  pseudarthrosis  produced 
in  this  way  in  the  centre  of  a  partially  ossified  mass. 
If  there  is  any  infection,  the  marrow  will  die  and  disap- 
pear, a  n  d  n  o 
bone  -  forming 
tissue  will  be 
there  to  fill  the 
central  cavity  ; 
thenceforward 
an  infected  ca- 
vity will  persist 
in  the  centre  of 
the  bone,  the 
cure  of  which 
will  be  difficult 
if  not  impossible. 
If,  on  the  other 
hand,  all  frag- 
ments of  bone 
forced  out  and 
displaced  by  the 
injury  are  re- 
moved, and  one 
side  only  of  the 
shaft  is  allowed 
to  remain,  the 
periosteum  will 
be  grouped  by 
inuscular  pres- 
sure   round    the 


Figs.  21  and  22. — ^These  two  radiographs, 
taken  at  three  months'  interval,  show  well 
how  fragments  left  in  place  cause  an  out- 
ward bulging  of  the  periosteum,  and  how, 
owing  to  this,  a  central  cavity  is  fornied 
within  the  callus.     Compare  fig.   10. 


grooved  bar  remaining,  and  the  callus  will  form  along 
this  in  the  shape  of  a  regular  solid  column,  with  no 
gap  or  infected  cavity  :  bone-formation  is,  as  it  were, 
guided,  and  the  callus  thus  produced  will  give  in- 
finitely more  security  for  the  future  than  one  built 
around  diseased,  dead,  or  displaced  fragments. 

Decidedly,  instead  of  hesitating  at  wide  preventive 


328 


TREATMENT    OF    FRACTURES 


esquillectomy,  the  surgeon  should  regard  it  as  the 
ideal  operation  for  fractures,  since,  while  entirely  pro- 
tecting the  bone-forming  tissues  from  damage  by 
infection,  it  ensures  the  formation  of  a  healthy  callus 
in  a  regular  way — a  callus  enclosing  no  undesirable 
foreign  body,  nor  threatening  any 
subsequent  formation  of  fistulae. 

B.  Secondary  operative  disinfection 
of  clinically  infected  fractures :  Es- 
quillectomy and  drainage  :  total  sub- 
periosteal esquillectomy. 

The  reasons  for  regarding  wide 
sub-periosteal  esquillectomy  as  the 
preventive  operation  par  excellence, 
should,  for  stronger  reasons,  bring  it 
to  be  regarded  as  the  only  form  of 
intervention  ensuring  the  disinfec- 
tion of  recently  infected  fractures. 
It  is  a  typical  drainage  operation, 
since  it  completely  exposes  the  in- 
jured area,  and  abolishes  everything 
which  could  facilitate  the  develop- 
ment of  infection,  i.e.  the  closed 
cavity,  unhealthy  debris,  and  tissue 
of  diminished  vitality 

Practically,  it  rules  out  all  serious 
sepsis,  rapidly  removes  less  serious 
infection  which  is  tending  to  become 
chronic,  and  quickly  abolishes  all 
infections  which  cannot  develop  in 
the  presence  of  air :  it  thus  assures 
the  regular  formation  of  a  healthy,  and  in  no  way 
pathological,  callus.  This  callus  is  not  an  outer  shell 
enclosing  an  empty  central  cavity,  but  a  compact, 
connecting  column,  in  one  piece,  having  nothing  in 
common  with  the  misshapen  callus  produced  by  a 
diseased  periosteum  round  an  infected  medullary  cavity. 


Fig.  23. — Bridge 
of  periosteal  callus 
formed  along  an  ad- 
herent fragment  in 
the  lower  third  of 
the  tibia ;  the  splin- 
ter, which  occa- 
sioned a  fistula, 
had  to  be  removed ; 
the  protruding  cal- 
lus ulcerated  the 
skin  of  the  leg,  and 
had  to  be  removed 
later  in  order  to 
bring  about  healing. 


GENERAL  PRINCIPLES  IN  TREATMENT  329 


No  other  operation  can  fulfil  these  purposes  ;  if  any 
fragments  of  diminished  vitality,  around  which  infec- 
tion may,  and  often  does,  develop,  are  left  in  a  frac- 
ture, the  operation  is  not  one  to  be  relied  on  to  give 


Fig.  24. — Copy  of  a  radio- 
graph made  after  secondary  sup- 
plementary esqviillectomy  on  the 
thirteenth  day  for  fracture  of 
the  thigh.  A  large  adherent 
splinter  left  in  place  was  re- 
moved, as  were  two  pieces  of 
shell,  one  of  which  was  in  the 
medullary  canal.  The  suppura- 
tion stopped  at  once  without 
the  use  of  an  antiseptic. 


Fig.  25.^ — Sketch  showing  the 
callus  obtained  in  sixty  days. 
Union  had  occurred  forty-eight 
days  after  the  operation.  The 
patient  could  walk  on  the  sixty- 
second  day. 

an     invariable    and    sure 
result. 

It  is  not    a  matter   of 


mere  drainage  of  the  soft 
parts.  The  pathological  physiology  of  infections  for- 
bids any  thought  of  that. 

Partial  and  prudent  esquillectomy,  i.e.  a  hesitating 


330 


TREATMEKT    OF    FRACTURES 


md  incomplete  operation,  is  fatal  in  leaving  the 
principal  infected  area  untouched  :  it  deliberately 
avoids  the  root  of  the  trouble,  and  permits  neither  a 
thorough  search  for  fragments  of  metal  and  clothing 
nor  an  exploration  of  the  medullary  canal,  which  is 
absolutely  necessary.  It  limits  itself  to  a  little  tenta- 
tive draining,  and  is  often  carried  no  further  than 
this  ;  soonei-  or  later  amputation  is  necessary  in 
cases  which  this  method  has  proved 
incapable  of  curing.  It  is  easily 
judged  to-day  by  its  results  ;  it  has 
peopled  our  towns  with  men  who 
have  lost  limbs  and  has  filled  the  hos- 
pitals with  unfortunate  men  whose 
wounds  have  been  suppurating  for 
months,  almost  for  years,  still  pos- 
sessing incurable  sinuses  in  spite  of 
all  treatment. 

The  anatomical  and  pathological 
conditions  of  an  infected  fracture  are 
such  that  any  intervention  which  does 
not  establish  drainage  of  the  medul- 
lary canal  and  removal  of  all  debris 
about  to  undergo  necrosis  is  a  bad 
operatiDU.  Theoretically  this  is  so  ; 
it  is  also  true  in  practice. 

Blind  and  partial  oj^erations  should 
therefore   be   dismissed. 

On  the  other  hand,  wide  esquillec- 
tomy  which  allows  of  thorough 
exploration  of  the  wound,  removes 
necrosed,  infected,  or  infectable  tissue 
debris,  and,  having  thus  displayed 
the  wound  well,  leaves  in  it  only  elements  necessary 
for  repair,  and  at  once  and  invariably  ensures  automatic 
disinfection  and  drainage  ;  it  does  for  the  infected 
shaft-fracture  what  sub-periosteal  resection  will  do  for 
an  epiphyseal  fracture. 


Fig.  26. —Ra- 
diograph of  a  cal- 
lus in  the  iilna, 
six  mouths  after 
total  secondary 
e  s  quillectomy. 
Compare  figs.  95, 
96,  97,  98,  which 
illustrate  the  same 
case. 


GENERAL  PRINCIPLES  IN  TREATMENT     3;n 

Jt  should,  therefore,  be  employed  at  once  and  sys- 
tematically in  all  fractures  whose  course  is  not  clinically 
aseptic. 

What  has  been  said  of  periosteal  bone-formation 
after  sub-periosteal  esquillectomy,  and  the  X-ray 
photographs  which  will  be  found  in  the  book,  will 
suffice,  I  believe,  to  show  that  the  method  does  not 
tend  to  produce  pseudarthrosis. 

Briefly,  wide  sub-periosteal  esquillectomy  is  the  only 
logical  operation  in  Tiariyiony  with  present-day  anato^nico- 
pathological  theories  on  the  development  of  septic  frac- 
tures in  ivarfare. 

No  other  permits  complete  exploration  of  the  region 
concerned,  and  treatment  of  the  injuries  caused  by  the 
missile  after  thorough  exposure  of  the  wounds  to  the  air. 
Owing  to  the  exploration,  prevention  of  infection,  and 
drainage  ichich  it  includes,  this  inethod  alone  consistently 
achieves  continued  asepsis  of  the  fracture.  Thus  it  en- 
sures the  normal  production  of  a  healthy  callus  from  the 
bone-forming  tissues  which  it  has  preserved  in  thewound. 
These,  restored  by  the  rugine  to  their  position  in  relation 
to  the  shaft,  will  develop  a  regular  osseous  column  in  line 
with  the  shaft;  without  the  ernjity  central  cavity  which  is 
so  favourable  a  seat  for  chronic  infections. 

C.  General  indications  for  the  operation. 

1.    As  A  PREVENTIVE   OF  INFECTION. Sub-pcriostcal 

esquillectomy  should  be  carried  out  as  early  and 
promptly  as  possible  in  all  fractures  caused  by  fragments 
of  shell,  bomb,  or  torpedo,  or  by  bullets  with  accomjmnying 
explosive  effects.  In  all  these  cases  no  clinical  sign  of 
infection  should  be  waited  for  before  operating.  As 
in  all  penetrating  wounds  of  the  abdomen  or  joints, 
an  exploratory  transosseous  operation  is  absolutely 
necessary.  Apart  from  tracheotomy  or  the  ligature 
of  a  large  vessel,  no  class  of  case  calls  more  urgently 
for  intervention  than  this  :  in  the  ambulance,  the 
exjiloration  of  limb  fractures  should  be  carried  out 


332        TREATMENT    OF    FBACTUBES 

immediately  ;  if  it  is  a  matter  of  choosing  between 
several  cases,  some  of  which  will  be  obliged  to  wait, 
fractures  sho7itd  receive  attention  first. 

In  the  event  of  a  rush,  the  sujgeon  at  the  front 
is  strictly  bound  to  deal  with  the  greater  number,  and 
with  those  whose  life  he  is  most  certain  of  saving,  and 
whose  condition  he  is  best  able  to  improve.  He  is 
under  a  definite  obligation  to  operate  on  fractures 
rather  than  abdominal  cases  should  they  arrive  simul- 
taneously, unless  he  is  certain  of  being  able  to  deal 
with  all  within  a  limited  time  :  twenty  esquillectomies 
are  worth  more  than  ten  laparotomies,  the  definite 
gain  from  the  humane  point  of  view  being  greater. 

It  goes  without  saying  that  these  rules  are  irrelevant 
to  periods  of  relative  quietness,  when  there  is  time  for 
everything. 

But  tohat  should  be  done  in  the  case  of  shock  ? 

Many  cases  of  fracture,  particularly  those  of  the 
thigh,  are  in  a  condition  of  severe  shock.  Should  the 
operation  be  postponed  until  the  next  day  ?  Are 
these  cases  in  too  critical  a  condition  for  a  general 
anaesthetic  and  a  necessarily  rather  long  operation  ? 
A  careful  esquillectomy  requires  half  to  three-quarters 
of  an  hour  :  is  this  not  too  much  for  men  who  are 
faint  and  chilled  ? 

Yet  complications  may  be  imminent.  A  case  ex- 
hibiting severe  shock  is  sometimes  threatened  by 
serious  infection,  and  will  not  survive  unless  an  im- 
mediate operation  is  performed. 

Theoretically  the  question  appears  insoluble ;  practi- 
cally, it  is  a  matter  of  judgment.  A  case  exhibiting 
severe  shock  wiU  not  be  transferred  direct  from 
the  stretcher  to  the  operating-table  ;  the  first  step 
is  to  treat  the  shock.  The  patient  is  placed  in  bed 
in  the  horizontal  position  with  the  head  low,  and 
is  warmed,  and  01  grm.  morphine  is  immediately 
given  :  morphine  acts  marvellously  in  the  majority  of 
cases,  apparently  counteracting  the  peripheral  vase- 


GENERAL  PRINCIPLES  IN  TREATMENT    333 

constriction.  By  a  reverse  process  a  similar  effect 
may  be  attempted,  by  endeavouring  to  induce  contrac- 
tion of  the  abdominal  vessels  in  order  to  restore  the 
quantity  of  blood  contained  in  them  to  the  general 
circulation  :  this  justifies  the  use  of  emetine  (05  to  *1 
grm),  or  of  pituitrine  :  this  method  is  superior  to 
the  injection  of  quantities  of  saline,  which  perhaps 
often  has  an  effect  opposite  to  that  desired.  On  the 
other  hand,  small  doses  (150-200  grm.)  of  very  warm 
saline  containing  adrenalin,  injected  intravenously, 
and  repeated  every  two  hours,  give  excellent  results. 

After  five  or  six  hours  the  operation  is  performed.  It 
should  not  be  delayed  longer  ;  shock  which  resists  the 
above  treatment  has  a  permanent  cause  in  the  region 
of  the  wound  which  must  be  removed  at  once.  Some 
of  these  operation  cases  will  die,  but  experience  shows 
that  in  these  fatal  cases,  shock  persists  until  death, 
and  nothing  would  have  been  gained  by  waiting. 
Others  recover  without  difficulty. 

Is  it  possible  to  distinguish  between  these  cases  ? 

Clinically  not,  but  Sencert  has  shown  that  the 
height  of  the  blood-pressure  gives  definite  informa- 
tion :  there  is  a  minimum  pressure,  and  should  the 
patient's  fall  lower  than  this,  there  is  every  likelihood 
that  he  will  succumb  rapidly.  All  cases  which  Sencert 
has  seen,  whose  blood-pressure  before  the  operation, 
measured  by  Vaques'  apparatus,  was  below  10,  died : 
the  rest  recovered.  Apart  from  this  excellent  pro- 
cedure, there  is  no   definite  anti-operative  indication. 

In  the  absence  of  shock,  should  all  fractures  be 
treated  by  immediate  operation  ?  Yes,  all  fractures 
by  fragments  of  shell,  bomb,  or  torpedo,  or  by  bullet  with 
accompanying  explosive  effects. 

In  fractures  by  shrapnel  balls,  shown  by  X-rays  to 
be  such,  a  few  hours'  delay  is  theoretically  justified, 
if  time  is  plentiful,  to  decide  whether  an  operation 
shall  be  performed.  Infection  is  less  constant  in  these 
cases  than  in  fractures  by  a  shell-fragment.     Arrange- 


334        TREATMENT    OF    FRACTURES 

ments,  however,  should  be  made  for  the  case  being 
watched  closely,  for  there  are  a  number  of  these  frac- 
tures whose  course  is  identical  with  that  of  the  worst 
shell-fragment  fractures  (those  in  which  the  bullet, 
originally  spherical,  but  more  or  less  deformed  on 
impact,  has  carried  in  fragments  of  clothing  with  it). 
If,  therefore,  there  is  a  large  influx  of  wounded,  there 
should  be  no  delay  ;  the  fracture,  though  perhaps 
benign,  is  treated  like  the  rest,  rather  than  risk  death 
from  sepsis,  or  an  amputation,  in  a  case  which  origin- 
ally appeared  the  least  serious  of  all. 

In  practice,  I  think  it  better  to  make  no  distinction 
between  fractures  by  shrapnel  balls  and  others  ;  the 
fundamental  rule  of  prevention  holds  here  as  elsewhere, 
and  it  is  better  to  perform  the  operation  in  nine  cases 
not  requiring  it  than  to  lose  a  single  life  by  refraining 
from  it.  It  is,  moreover,  certain  that  the  nine 
operations  will  not  prove  to  have  been  useless. 

In  bullet  fractures  with  small  skin  wounds,  but 
larger  than  the  punctiform  type,  clinical  signs  should 
be  awaited,  and  treatment  limited  to  immobilisation. 
Infection  is  not  usually  fatal  ;  it  is  often  benign,  and 
the  patient  can  be  evacuated  forthwith.  But  if  the 
wound  of  exit  exceeds  one  inch  in  breadth,  immediate 
preventive  intervention  is  required,  since  serious  in- 
fection is  usual  in  this  case. 

2.   As  AN  OPERATION  FOR  DRAINAGE. Sub-pcriostcal 

esquillectomy  should  be  done  at  once  in  all  clinically 
infected  fractures,  and  in  any  seen  after  twenty- 
four  hours  or  later.  It  should  be  practised  even  if 
there  has  been  an  earlier  intervention,  should  the 
case  present  •  signs  of  increasing  infection,  or  if  the 
wound  is  suppurating  after  an  interval  of  several 
days.  This  is  frequently  seen  at  base  hospitals.  In 
fact,  the  majority  of  cases  sent  back  from  the  front 
are  suppurating  to  some  extent,  in  spite  of  various 
antiseptic  dressings.  These  wounds  appear  clean,  but 
they  are  never  aseptic  ;   the  infection  is  slight,  but  it 


GENERAL  PBINCIPLES  IN  TREATMENT     iJiio 

is  nevertheless  an  infection,  and  this  should  not  be 
so.  Suppuration  after  five,  six,  or  eight  days,  and 
])articularly  after  a  longer  time  than  this,  is  indis- 
putable proof  that  the  original  cleaning  was  incom- 
])lete,  and  that  there  are  still  fragments  of  bone  and 
gangrenous  tissue  to  be  I'emoved  which  have  been 
left  in  the  wound,  involuntarily  or  not  :  to  speak 
])lainly,  the  operations  in  these  cases  have  been  incom- 
plete. 

In  fourteen  shaft  fractures  arriving  in  fifteen  days 
during  an  offensive,  I  found  under  X-rays  splinters 
undergoing  necrosis  in  fourteen  cases,  and  in  all  the 
cases  I  operated  to  remove  them.  In  eleven  cases  care- 
ful and  methodical  sub-periosteal  esquillectomy,  ethyl 
chloride  being  used  as  an  anaesthetic,  was  sufficient  to 
arrest  suppuration  and  enable  the  injury  to  take  a 
dimcally  aseptic  course. 

This  result  could  have  been  obtained  at  the  outset. 
In  five  cases  adherent  splinters  were  removed  in  which 
were  engaged  fragments  of  clothing  whose  spontaneous 
elimination  ap])eared  impossible.  In  three  cases  suc- 
cessive ojierations  were  required  for  the  draining  of 
abscesses,  and  an  aseptic  condition  of  the  wound  was 
only  obtained  at  the  end  of  a  fortnight. 

It  will  perhaps  be  said  that  this  secondary  cleaning 
was,  to  say  the  least,  useless,  and  that  the  majority 
of  the  cases  would  have  recovered  equally  well  had  I 
left  them  quiet  and  well  immobilised. 

This  is  not  my  opinion  :  I  believe  it  to  be  very 
bad  for  a  fractured  bone  and  the  surrounding  muscles 
to  be  in  prolonged  contact  with  pus.  The  production 
of  leucocytes  and  the  proteolytic  2:)henomena  which 
lead  to  the  elimination  of  dead  tissue,  result  in  iriita- 
tion  of  the  periosteum,  in  sclerosis  of  the  muscles,  and 
in  perceptible  interference  with  recovery  of  function  in 
the  wounded  limb.  It  is  a  mistake  to  regard  suppura- 
tion, even  of  a  benign  nature,  of  war-wounds  as  an 
almost  normal  phenomenon  ;    it  will  be  asked   with 


336  TREATMENT    OF    FRACTURES 

astonishment  in  tlie  near  future  how  it  has  been  pos- 
sible for  so  important  a  factor  in  anatomical  and 
functional  recovery  to  be  misunderstood. 

To  return  to  my  cases.  1  do  not  doubt  that  in  a 
few  of  them  suppuration  would  slowly  have  elimin- 
ated some  of  the  splinters  which  I  removed,  and 
union  would  eventually  have  taken  place  without  a 
second  operation;  but  I  am  certain  that  the  callus 
produced  in  this  way  would  have  been  inflamed,  bulky, 
and  painful.  Now  this  result  seems  to  me  far  from 
the  ideal  which  should  be  aimed  at  in  war  surgery 
at  the  present  day.  There  are  calluses  and  calluses  ; 
only  aseptic  callus-formation  should  be  sought  after, 
and  it  is  certainly  being  content  with  little  to  be 
satisfied  with  having  obtained  union  of  diseased  bones 
with  osteomyelitic  extremities. 

A  pathological  callus  is  a  had  callus,  and  a  reproach 
to  the  surgeon.  Any  fracture  whose  fragments  are 
united  by  a  section  of  inflamed  bone,  produced  by 
diseased,  swollen,  and  hypertrophied  periosteum,  en- 
circling a  cavity  of  varying  size  which  contains  free 
or  fixed  dead  splinters,  is  a  fracture  viciously  united 
after  having  been  badly  treated  at  the  original  opera- 
tion. Similarly  with  sinuses.  Up  till  now  only 
anatomically  defective  callus  has  been  considered 
vicious ;  that  is,  the  cases  in  which  the  normal  axis  of 
the  limb  has  not  been  restored,  or  articular  surfaces 
below  the  fracture  have  been  left  in  abnormal  relation. 
Up  to  the  present  pathologically  vicious  callus  has  been 
very  rife  ;  every  day  numerous  examples  are  seen  of 
diseases  of  the  callus,  not  formerly  known  to  exist, 
and  all  who  have  had  to  operate  on  these  are,  I  believe, 
already  convinced  that  pathological  callus  produced 
by  an  incomplete  operation  at  the  outset  is  more 
difficult  to  deal  with  than  the  anatomically  vicious 
form  produced  by  incompetent  post-operative  super- 
vision :  orthopaedic  surgery  is  more  sure  of  its  results 
than  the  surgery  of  the  results  of  infection. 


GENERAL  PRINCIPLES  IN  TREATMENT  337 

But  it  will  be  objected  that  eveiy  callus  is  not 
necessarily  inflamed  or  fistulous.  Decidedly  not,  but 
chronic  osteomyelitis  is  not  the  only  danger  that 
threatens  a  septic  fracture.  Pseudarthroses  are  pro- 
duced by  inflammatory  sterilisation  of  the  ends  of  the 
bone  ;  dense  calluses  also  occur,  with  marginal  osteitis, 
uniting  fractures  in  useless  limbs  riddled  with  inci- 
sions, with  sclerosed  and  rigid  muscles  and  tense, 
shining,  purplish  skin.  For  some  of  these  men,  con- 
demned to  ])ain  and  crutches,  an  early  amputation 
would  often  have  been  better  than  the  preservation  of 
such  a  limb  as  thi&. 

It  is  for  this  reason  that,  m  spite  of  the  opinion  of 
certain  surgeons,  when  a  fracture  suppurates  after  an 
originally  insufficient  intervention,  the  surgeon  should 
not   simply   wait   for   the   suppuration   to   cease  :     a 
further  attempt   should  he   made  to   render  the   injury 
aseptic  and  so  to  ensure  the  subsequent  regular  progress 
of  the  case.     A  more  or  less  early  secondary  esquil- 
lectomy  will  quickly  succeed  in  rendering  the  wound 
ase])tic  and  arrest  the  formation  of  pus  :  if  the  operator 
is  determined  to  do  it  strictly  sub-periosteally,  as  he 
easily  can,  owing  to  thickening  of  the  periosteum,  he 
will  have  the  satisfaction  of  seeing  union  occur  with- 
out complications  after  a  normal  la])se  of  time.     For 
this  a  far-reaching  operation  is  necessary — and  suffi- 
cient— ^one  which  achieves  at  once  what  others  expect 
suppuration  to  perform,  at  the  ex23ense  of  considerable 
injury  to  bone  and  surrounding  soft  parts — i.e.   the 
removal   of  tissue  undergoing,   or  about  to  undergo, 
necrosis,    contused    surrounding    skin,    crushed    and 
lacerated  muscles,  splinters  torn  away  and  displaced  : 
it  should  leave  nothing  to  he  eliminated  spontaneously. 
The  esquillectomy  itself  should  remove  not  only  free 
splinters  embedded  in  muscles  or  imprisoned  far  up 
the  medullary  canal,  hut  also,  and  principally,  adherent 
splinters,  already  diseased,  which  bar  the  way  to  the 
medullary  canal,  and  are  found  with   their  surfaces 


TREATMENT    OF    FRACTURES 


rough  and  disintegrated.  Some  surgeons  recommend 
drawing  subtle  distinctions  between  splinters  by  their 
colour  and  resonance  when  struck  by  an  instrument. 
There  is  no  object  in  attem])ting  such  a  differentiation, 
01-  in  leaving  in  the  wound  useless  structures  of  dimin- 
ished vitality,  which  will  for  a  long  time  encourage 
suppui-ation,  and  ultimately  die.  Tf  the  periosteum 
is  carefully  2)reserved,  everything  is  retained  in  the 

wound  necessary  for 
the  formation  of  an 
ample  quantity  of 
healthy  bone  ;  there 
is  no  risk  of  pseud- 
arthrosis,  and  the 
column  of  bone  thus 
formed  will  always 
be  almost  exactly  of 
the  same  length  as 
the  original  shaft, 
much  more  nearly  so 
than  in  the  case  of  a 
fracture  in  which  the 
splinters  have  been 
retained. 

In  every  case  after 

such       intervention, 

and  without  the  use 

of     antiseptics,     the 

wound        invariably 

becomes  aseptic  in  a 

short    time    (usually 

five  or  six  days).     If 

the  suppuration  lasts 

longer,     the    reason 

undoubtedly  is  that 

a  splinter  in  a  corner  of  the  wound  has  been  forgotten. 

A  verification  by  X-rays  should  be  carried  out  without 

delay,  and  any  fragments  remaining  should  be  removed. 


Fio.  11.  — Jii- 
fected  fracture  of 
the  liuiJieras, 
tliree  days  old. 


FiG.  28.— Con- 
di tioa  of  the  frac- 
ture three  days 
after  total  sub- 
periosteal esquil- 
lectouiy. 


GENERAL  PRINCIPLES  IN  TREATMENT    330 


Thenceforward  there  need  be  no  furthei'  fear  of 
purulent  cavities,  muscular  sclerosis,  or  neighbouring 
phlebitis.  The  callus  about  to  form  will  be  healthy, 
built  up  in  a  nor- 
mal length  of  time 
by  vigorous  osteo- 
genetic  tissue, 
whose  functional 
activity  is  unim- 
paired by  any  in- 
fection. 

Counter  -  indica- 
tions.—  But  al- 
though secondary 
sub-periosteal  es- 
quillectomy  is  in- 
dicated in  recent 
fractures  not  yet 
united  {i.e.  less 
than  a  month 
old),  it  is  never- 
theless dangerous 
in  old  suppurating 
fractures  where 
new  bone  is  in  con- 
tact with  old  and 
diseased  bone.  In 
this  case,  wide 
clearance,  which 
must  traverse  a 
barrier  of  newly 
formed  bone, 
causes  violent  in- 
jury in  a  closed 
space,    opens    up 

large  areas  for  absorption,  and  regularly  causes  sud- 
denly acute  sepsis,  always  very  serious,  sometimes 
fatal,  and  likely  to  demand  immediate  amputation. 


Fig.  29. —Same 
case  as  in  figs.  27 
and  28.  Radio- 
graph made  at  the 
end  of  five  weeks  ; 
there  was  very  little 
pus-formation.  The 
wound  not  being 
completely  closed, 
I  was  able  to  pass 
forceps  in  and  re- 
move the  small  free 
sequestrum  seen 
here. 


Fig.  30.  —  Con- 
dition at  the  end  of 
sixty  days.  The 
muscles  are  all  pre- 
served intact.  It  is 
impossible,  on  see- 
ing the  play  of  the 
limb,  to  guess  that 
the  patient  has  had 
a  serious  fracture. 


340       TREATMENT    OF    FRACTUBES 

Esquillectomy,  in  such  injuries  which  can  be  in- 
vestigated only  with  difficulty,  is  certain  to  leave 
behind  it  recesses  and  infected  fissures  :  only  sub- 
periosteal resection  of  the  shaft  will  expose  all  the 
diseased  tissue  and  allow  of  its  being  dressed. 

Fo7'  this  reason,  esquillectomy  should  never  be  at- 
tempted after  consolidation  has  commenced.  The  surgeon 
should  limit  himself  to  draining  abscesses  and  remov- 
ing obvious  sequestra  with  forceps ;  spontaneous 
elimination  of  the  rest  must  be  relied  on,  and  no 
attempt  made  to  get  the  sinuses  to  close  until  the 
proliferation  of  firm  bone,  enclosing  the  sequestra, 
has  definitely  localised  the  area  of  infection. 

If  the  general  indications  given  here  are  followed, 
the  treatment  of  fractures  will  be  found  to  be  sim- 
plified enormously.  They  will  run  an  aseptic  course, 
without  tracks  of  pus,  abscesses  far  removed  from 
the  injury,  secondary  haemorrhages,  or  elimination  of 
sequestra.  They  will  consolidate  without  forming 
sinuses,  and,  when  the  callus  is  formed,  cure  will  be 
final,  without  complications,  and  without  the  reappear- 
ance of  infection. 

3.  Special  Indications  :  Particular  Cases  :    the 

CHOICE    between   ESQUILLECTOMY  AND   AMPUTATION. 

—So  far  I  have  only  discussed  splintered  fractures 
evidently  justifying  an  operation  for  restoring  con- 
tinuity and  function;  but  should  not  the  extent  of 
the  injury  sometimes  demand  an  amputation  ? 

In  other  terms,  what  are  the  anatomico-pathological 
limits  of  esquillectomy  ? 

In  the  upper  limb  I  know  of  none,  apart  from  irre- 
parable injuries  to  blood-vessels  and  nerves.  For 
anyone  who  can  make  the  necessary  incisions  and  can 
use  a  rugine  suitably,  there  is  no  bone  injury  that  can 
in  itself  necessitate  amputation.  If  there  is  any  pro- 
spect of  preserving  normal  function  in  the  fingers,  a 
conservative  operation  may  always  be  performed, 
apart  from  removing  the  humerus  in  its  whole  extent. 


GENERAL  PRINCIPLES  IN  TREATMENT    341 

or  a  large  extent  of  bone  in  the  forearm  ;  even  entire 
removal  of  the  humerus  is  permissible,  and  I  have 
personally  resorted  to  it  in  one  case.  Certainly 
periosteal  regeneration  of  the  bone  removed  cannot 
always  be  expected,  but  an  artificial  structure  will 
replace  it,  and  no  amputation  stump  can  compare 
with  a  functional  hand  at  the  end  of  a  flail-arm.  But 
if  muscular  destruction  is  considerable,  and  if  impor- 
tant tendons  have  been  destroyed  over  a  wide  extent 
{e.g.  severance  of  the  flexors  or  extensors  of  the  fingers), 
preservation  is  pointless  and  amputation  should  be 
preferred. 

Similarly  if,  together  with  extensive  injuries  to 
bone  and  muscle,  the  three  nerves  of  the  hand  have 
been  severed  in  the  arm,  it  is  unreasonable  to  hope 
for  regeneration  of  the  median,  radial,  and  ulnar, 
when  their  point  of  injury  is  in  the  region  of  a  serious 
fracture.  Under  these  conditions,  esquillectomy  should 
be  rejected,  and  the  radical  operation  preferred. 

An  isolated  arterial  or  venous  lesion  does  not  in 
itself  contra-indicate  esquillectomy  :  the  vessel  may 
simply  be  tied  in  a  suitable  place,  and  the  operation 
on  the  bone  be  performed  as  usual. 

In  the  lower  limb  the  factors  concerned  are  different. 
The  function  of  the  lower  limb  being  to  support  the 
weight  of  the  body  in  an  upright  position  and  in  walk- 
ing, the  solidity  of  the  limb  takes  precedence  of  all 
other  consideration?  ;  the  only  conservative  surgery 
is  that  which  preserves  function,  and  it  is  not  pre- 
serving function  to  retain  a  thigh  or  leg  which  is  not 
rigid.  Esquillectomy  is  therefore  not  justified,  unless 
followed  by  a  regeneration  of  bone  sufficient  to  ensure 
solidity.  According  to  very  wide  investigation,  apart 
from  some  exceptional  cases  of  very  extensive  regenera- 
tion, I  believe  that  any  initial  clearance  which  leaves 
a  gap  5  to  6  in.  long  in  a  bone  essential  to  the  up- 
right position  (femur,  or  tibia),  is  a  doubtful  operation 
to  which  amputation  is  preferable.     Of  course  esquil- 


342         TREATMENT   OF   FRACTURES 

lectomy   may   be   carried   out   in   the   first   instance, 
amputation  being  postponed  for  some  days,  in  order 
that  the  latter  may  be  carried  out  more  regularly, 
at  leisure,  and  with  more  discrimination  under  aseptic 
conditions.     It  would  also  be  possible,  after  extensive 
removal  of  bone,  to  attempt  a  bone-graft :   early  sub- 
periosteal esquillectomy  having  reduced  the  injured 
area  to  an  aseptic  condition,  the  graft  could  be  placed 
early  in  aseptic  surroundings  and  have  some  chance 
of  success.     It  would  be  equally  possible  to  attempt 
a  bone-graft  from  a  fresh  corpse.     This  is  a  reasonable 
alternative,  for  theoretically  it  is  correct  to  hope  for 
a  good  result ;  but  this  is  not  the  place  for  discussing 
these  methods,  and  they  cannot  affect  what  I  have 
said  above^ — there  are  injuries  of   the  femur  which 
should  be  recognised  at  once  as  requiring  amputation. 
In  later  stages  attempts  at  preservation  may  be 
carried   further,    regeneration    of     bone    being    more 
abundant.     But  nothing  should  be  exaggerated,  and 
the  above  figures  are  almost  a  maximum. 

Briefly,  in  present-day  surgery,  a  fracture  of  the 
femur  or  tibia  involving  loss  of  more  than  6  inches 
of  the  bone  should  be  amputated  at  once. 

Similarly,  certain  extensive  muscular  injuries  com- 
bined with  a  serious  fracture  may  demand  amputation. 
On  the  other  hand,  a  vascular  lesion  should  not,  as 
a  rule,  affect  the  treatment  which  the  fracture  appears  • 
to  require.  After  ligature  of  the  femoral,  esquillectomy 
in  the  thigh  is  still  an  excellent  operation,  provided 
that  the  shock  be  not  too  great. 

Nervous  lesions  (severance  of  the  sciatic)  should  not 
modify  the  treatment  of  the  fracture. 

The  main  factors  governing  the  advisability  of 
esquillectomy  may  be  summarised  as  follows  : 

In  the  ufj^er  limb,  esquillectomy  shd(ald  he  done,  ivhat- 
ever  the  extent  of  the  injury  to  the  hone,  wheriever  {apart 
from  complete  cure)  satisfactory  recovery  of  function  in 
the  hand  is  assured. 


GENERAL  PRINCIPLES  IN  TREATMENT    3i;3 

In  the  lower  limb,  it  should  he  rejected  whenever  re- 
covery of  the  function  of  support  cannot  he  expected. 
D.  Technique  of  sub-periosteal  esquillectomy. 
This  is  a  delicate,  minute,  and  deliberate  operation, 
which  demands  time,  patience,  and,  if  possible,  an 
exact  previous  knowledge  of  the  topography  of  the 
fracture.  There  is  every  advantage  in  not  under- 
taking it  until  after  X-ray  examination  or  complete 
X-ray  photography  from  both  the  lateral  and  anterior 
aspects,  permitting  accurate  estimation  of  the  number 
and  position  of  the  missiles,  and  appreciation  of  the 
rough  shape  of  large  splinters  and  the  general  arrange- 
ment of  the  injured  region. 

1.  Anesthesia. — Esquillectomy  requires  complete 
anaesthesia  ;  in  no  case  should  the  surgeon  be  content 
with  a  local  anaesthetic.  The  operation  may,  in  fact, 
be  a  long  one,  and  its  extent  is  sometimes  much  greater 
than  was  at  first  anticipated.  I  habitually  use  ethyl 
chloride  on  an  open  mask,  which  allows  of  an  opera- 
tion lasting  three-quarters  of  an  hour  to  an  hour  with 
the  advantage  of  immediate  anaesthesia  and  rapid  and 
uncomplicated  recovery  of  consciousness,  two  much- 
appreciated  features  in  a  very  busy  hospital.  For  the 
lower  limb,  spinal  anaesthesia  by  novocaine  and 
adrenalin  is  extremely  convenient. 

2.  Disinfection  of  the  soft  parts.- — It  is  of  great 
importance  to  begin  the  operation  by  carefully  dis- 
infecting the  wounds  of  entry  and  exit.     The  contused 
cutaneous   edges  of  each  orifice   should  be  excised  ; 
then,  the  wound  having  been  enlarged  anatomically 
in  the  way  described,  the  fascial  sheath,  which  is  usually 
little  lacerated,  and  tensely  stretched  over  the  struc- 
tures beneath  it,  is  incised  to  the  extent  necessary  to 
display  the  whole  of  the  injured  region.     Then,  with- 
out introducing  the  fingers  in  a  clumsy  attempt  at 
removing  fragments,  two  retractors  are  placed  in  the 
wound,  permitting  inspection  of  its  superficial  features, 
intermuscular   intervals,   tendons,    and   so   on.     Any 


344        TREATMENT    OF   FRACTURES 

contused  and  lacerated  muscle  or  other  soft  tissue  is 
removed  with  great  care  by  means  of  forceps,  and  the 
smallest  fragments  of  clothing  or  soil  are  looked  for  ; 
in  fact,  the  whole  wound  is  cleaned  as  patiently  and 
minutely  as  possible. 

At  the  exit  wound  even  greater  care  is  required ; 
the  muscles  are  often  filled  with  osseous  debris  and 
minute  splinters  of  bone,  which  should  be  removed 
with  the  utmost  care.  Gentle  separation  of  fasciae 
.and  muscles  will  reveal  scraps  of  clothing  so  situated 
that  they  might  well  have  escaped  observation. 
Ecchymotic  patches,  which  often  undergo  necrosis,  are 
usually  found  in  contused  muscles,  at  some  distance 
from  the  main  injury  ;  the  exploration  of  the  soft 
parts  must  therefore  be  carried  to  the  extreme  limits 
of  the  injured  region.  All  suspected  patches  should 
be  widely  excised ;  even  parts  should  be  removed 
which  appear  simply  lowered  in  vitality,  and  which 
the  surgeon  might  feel  inclined  to  leave  untouched. 
These  strict  measures  are  necessary  in  order  to  avoid 
the  disagreeable  surprise,  some  days  later,  of  finding 
large  patches  of  necrosis  in  a  wound  which  had  been 
supposed  healthy. 

The  entry  and  exit  wounds,  when  suitably  enlarged, 
will  serve  for  the  esquillectomy  if  they  are  conveni- 
ently situated.  When  this  is  not  so,  if,  for  instance, 
both  are  on  the  same  aspect  of  the  limb,  or  if  they  are 
too  far  apart,  and  far  from  the  fracture,  as  is  the  case 
when  the  track  of  the  projectile  is  very  oblique,  or  if 
they  are  situated  in  a  dangerous  area,  they  should 
merely  be  cleaned  and  freed  of  injured  tissue  as  above 
described,  and  the  bone  operation  should  be  per- 
formed through  a  fresh  incision  made  in  a  suitable 
position. 

Metallic  fragments  are  removed  at  once,  if  neces- 
sary, by  means  of  fresh  incisions.  The  bistoury  and 
forceps  should  then  be  used  along  the  track  in  the 
opposite  direction  to  that  taken  by  the  missile  until 


GENERAL  PRINCIPLES  IN  TREATMENT     345 

the  fracture  is  reached ;    here  fragments  of  clothing 
and  dead  splinters  will  usually  be  found. 

3.  Treatment  of  the  bone. — ^Near  the  bone,  par- 
ticularly on  the  side  of  the  exit  wound,  numerous 
splinters  will  be  found.  Previous  to  digital  explora- 
tion or  blind  search  with  instruments,  two  retractors 
are  introduced,  and  the  first  step  is  to  remove  with 
forceps  all  absolutely  free  splinters  scattered  in  the 
wound.  They  are  generally  completely  detached,  no 
adherent  fragments  of  periosteum  retaining  them  ; 
their  tendency  is  to  work  out  spontaneously,  and  their 
removal  is  an  easy  matter.  This  is  carried  on  towards 
the  shaft  itself.  From  this  point  onwards  all  inter- 
ference must  he  strictly  sub-periosteal,  and  the  slightest 
attachments  of  periosteum  must  be  preserved.  For  this 
purpose  each  adherent  splinter  is  gripped  by  means 
of  small  forceps  *  or  a  volsella,  and  the  rugine  is  used 
to  scrape  the  periosteum  carefully  away  from  it,  not 
to  liberate  the  splinter,  but  in  order  to  leave  the 
osteogenetic  tissue  covering  it,  in  the  wound.  The 
nearer  to  the  region  of  adherent  splinters  the  greater 
should  be  the  care  exercised.  The  very  natural 
temptation  to  tear  away  what  still  holds  by  a  sharp 
pull  or  violent  twisting,  must  be  resisted,  as  only  the 
fibrous  tissue  is  separated  in  this  way,  the  bone-form- 
ing layer  remaining  adherent  to  the  bone  ;  only  patient 
and  methodical  use  of  the  rugine  will  preserve  the 
whole  of  this,  together  with  the  non-osteogenetic 
external  periosteum.  For  this  purpose  the  cutting 
rugine  of  Oilier  which  I  have  described  in  Part  I 
(p.  30)  is  absolutely  necessary ;  those  who  do  not 
use  it,  but  employ  other  instruments  (the  rugines 
of  Farabeuf  and  Legouest),  cannot  be  aware  of  the 
difference  between  the  two  instruments. 

I  have  already  stated  what  adherent  splinters  should 
be  removed  ;   all  that  are  found  to  be  loose,  all  whose 

*  Heitz-Boyer   has  recently  had  forceps  made  by  Collin  which 
seem  to  me  perfect  for  this  purpose,  so  good  is  their  grip. 


346         TREATMENT   OF   FRACTURES 


reduced  vitality  will  later  be  further  lowered  even  by 
a  slight  infection,  and  finally  all  which  block  the 
way  to  the  medullary  canal,  and  prevent  exploration 
of  it,  should  be  removed.  It  is  for  these  that  the 
patient  use  of  a  very  sharp  rugine  is  absolutely  neces- 
sary :  no  fragment  of  periosteum  should  be  left  on 
the  bone  removed,  and  when  the  operation  is  finished, 
in  place  of  the  original  shaft  there  should  be  a  definite 

cylinder    of    peri- 


h=:A 


osteum,  remaining 
there  like  a  mould 
of  the  original, 
and  the  outline  of 
the  future  bone. 

Often,  in  de- 
taching visible  ad- 
herent splinters,  a 
large  and  still  ad- 
herent fragment 
will  be  disturbed 
whose  existence 
had  not  been  sus- 
pected ;  this  the 
surgeon  may  hesi- 
tate to  remove  on 
account  of  its 
length.  Its  removal  is  advisable,  since  shreds  of 
material  are  likely  to  be  adherent  to  its  deep  surface  : 
at  one  time  I  left  such  fragments,  now  I  remove  them, 
having  sometimes  seen  them  become  infected  and 
inflamed.  Moreover,  this  removal  is  not  a  disad- 
vantage, large  splinters  never  being  circumferential ; 
it  in  no  way  endangers  the  consolidation  of  the  bone 
if  the  periosteum  is  left  in  place,  and  the  procedure 
has  tjie  advantage  of  displaying  the  whole  area  affected 
by  the  fracture  and  levelling  recesses  where  infection 
might  develop  ;  for  these  reasons  it  should  be  carried 
out  without  hesitation.    In  other  cases,  on  the  borders 


Fig.  31. — Ollier's  cutting  rugines  with 
which  the  periosteum,  including  its  deep 
layer,  may  be  completely  detached. 


GENERAL  PRINCIPLES  IN  TREATMENT  347 

of  the  injured  region,  where  the  bone  is  healthy, 
two  splinters  are  sometimes  found,  1^  to  2  inches  in 
length,  obliquely  situated  outside  the  line  of  the  shaft, 
as  it  were  like  lateral  splints.  They  may  appear  per- 
fectly healthy,  but  if  they  are  left  they  frequently 
become  infected,  and  produce  excrescences,  contri- 
buting to  the  malformation  of  the  callus.  I  no  longer 
make  a  practice  of  retaining  these. 

It  is  not  easy  to  state  theoretically  how  far  esquil- 
lectomy  should  be  carried.  It  varies  with  different 
injuries  ;  the  essential  point  is  that  the  medullary 
canal  should  be  explored  thoroughly,  that  no  necros- 
ing debris  should  remain  there,  so  that  the  marrow 
may  be  scraped  away  as  far  as  the  injury  extends  and 
no  fragment  of  bone  remain  imprisoned. 

Clearance  should  be  more  complete  the  longer  the 
operation  is  delayed,  in  the  first  place  because  aseptic 
development  is  assured  from  the  outset  if  the  explora- 
tion has  omitted  nothing,  further  because  secondarily 
the  question  of  free  drainage  is  pre-eminent,  since  the 
periosteum  is  more  easily  detached  and  more  productive. 
In  brief,  at  the  outset,  wide  clearance  is  sufficient ; 
later,  it  is  often  better  to  carry  out  total  clearance. 

When  large  splinters  are  present,  this  sometimes 
results  in  leaving  nothing  in  the  wound  but  the  two 
pointed  extremities  of  the  shaft,  which  are  in  contact. 
Where  there  is  a  large  tangential  splinter  still 
adherent,  a  longitudinal  groove  is  left  in  which  bone 
is  rapidly  re-formed. 

On  the  other  hand,  in  fractures  involving  one  large 
short  fragment,  the  gap  left  will  merely  consist  of  a 
deep  notch. 

Where  there  are  many  small  splinters,  a  gap  IJ  to 
If  inches  in  length  will  often  remain. 

Finally,  in  transverse  fractures,  esquillectomy  is 
replaced  by  sub-periosteal  resection  of  the  crushed 
and  contused  ends  of  the  shaft,  in  order  to  produce 
a  drainage  gap  about  |  inch  in  width. 


348  TREATMENT   OF   FRACTURES 

The  essential  point  is  in  every  case  to  perform  every- 
thing slavishly  with  the  rugine,  and  to  preserve  all  the 
periosteum  that  can  be  found  anywhere. 

In  the  immense  majority  of  cases,  the  surgeon,  if 
he  is  patient  and  careful,  will  succeed  in  leaving  a 
more  or  less  complete  cylinder  of  periosteum,  or  a 
periosteal  sheath  unbroken  in  its  long  axis,  and  this 
will  suffice  for  the  formation,  in  a  normal  length  of 
time,  of  a  good  and  healthy  callus. 

This  done,  and  the  medullary  canal  being  well 
exposed,  it  is  cleaned  for  about  half  an  inch  with  a 
curette.  The  operator  will  always  be  surprised  at  what 
is  brought  to  light  in  this  way,  as,  for  instance,  fine 
splinters,  broken  scales  of  bone,  and  foreign  bodies 
(projectiles  and  fragments  of  clothing)  particularly  in 
the  regions  of  the  epiphyses.  This  curetting,  which 
should  be  performed  without  violence  or  excess,  is 
absolutely  necessary. 

When  the  wound  has  been  freed  from  splinters  and 
the  extent  and  variety  of  the  injuries  made  manifest, 
it  is  sometimes  necessary  to  trim  the  pointed  extremities 
of  the  injured  ends  of  the  shaft  by  means  of  cutting 
forceps.  In  certain  regions,  wherever  there  is  much 
cancellous  tissue,  and  close  to  epiphyses  particularly 
(notably  above  the  elbow  and  in  the  supra-malleolar 
region),  I  have  frequently  trimmed  the  ends  of  the 
shaft  with  a  saw  :  half  an  inch  of  the  bone  is  lost  in 
this  way,  but  absolutely  healthy  bone  is  reached,  and 
rapid  consolidation,  and  good  sound  callus,  amply 
compensate  for  this  slight  sacrifice  in  regions  which 
arie  dangerous  owing  to  the  proximity  of  joints.  There 
is,  however,  a  disadvantage  in  this  method  when  a 
secondary  esquillectomy  is  concerned :  the  end  of 
the  shaft  often  detaches  itself  after  some  weeks  in 
the  form  of  an  annular  sequestrum,  as  a  consequence 
of  death  of  the  marrow  and  detachment  of  the  peri- 
osteum.    This  is  sequestration  by  vascular  necrosis. 

Care  should  be  taken  throughout  to  secure  hemo- 


GENERAL  PRINCIPLES  IN  TREATMENT     349 

stasis  :  small  vessels  in  the  muscles  should  be  ligatured, 
and  at  the  end  of  the  operation  the  wound  should  be 
clean  and  dry,  without  clots  or  oozing. 

The  fracture  should  also  form,  as  it  were,  the  base 
of  the  wound  proper  {i.e.  injury  to  skin  and  muscles)  ; 
the  latter  should  not  stretch  over  and  mask  it,  but 
take  the  form  of  two  truncated  cones  meeting  at  their 
apices,  that  point  corresponding  with  the  centre  of 
the  medullary  canal. 

4.  Dressings. — The  necessity  of  loose  plugging,  and 
the  disadvantages  of  ^primary  or  secondary  suture.  A 
loose  mass  of  aseptic  gauze  is  placed  in  the  wound 
formed  as  above,  as  also  in  all  incisions  which  have 
been  required  for  the  removal  of  foreign  bodies  or  for 
any  other  reason.  Drainage  tubes  serve  no  purpose 
and  amount  merely  to  useless  foreign  bodies  :  I  never 
employ  them. 

Plugging  of  the  periosteal  cavity  is  necessary ;  the 
gauze  plays  the  part  of  an  irritant  which  others  expect 
infection  to  perform  ;  it  activates  the  periosteum,  and 
I  do  not  know  whether  ossification  would  be  so  satis- 
factory without  it.  It  also  prevents  approximation 
of  the  oppositing  layers  of  periosteum,  preserving  the 
shape  of  the  interfragmentary  space  in  which  bone- 
formation  will  take  place.  For  the  same  reasons  I 
regard  infrequent  dressing  as  advisable,  and  do  not 
recommend  either  immediate  or  secondary  attempts 
at  closure  of  the  wound.  Apart  from  the  risks  of 
infection  caused  by  immediately  closing  the  wound,  I 
consider  that  the  method  should  be  rejected  because 
it  prevents  reactivation  of  the  periosteum  which  is 
effected  by  plugging.*  I  have  on  several  occasions 
seen  consolidation  occur  in  twenty-four  hours  after 
the  third  or  fourth  dressing,  as  if  the  irritant  effect  of 

*  Oilier  taught  that  everything  should  not  be  sacrificed  to  the 
desire  for  a  rapid  cure  by  first  intention.  Aseptic  secondary  closure 
appeared  preferable  to  him  from  the  point  of  view  of  bone-formation. 
Everything  that  I  have  seen  up  till  now  leads  me  to  believe  that 
he  was  right. 


350  TREATMENT   OF   FRACTURES 

the  dressing  had  suddenly  released  a  new  activity  in  a 
still  perfectly  soft  callus. 

After  plugging,  the  limb  is  heavily  padded  and 
carefully  immobilised  by  one  of  the  methods  which 
will  be  suggested  later  for  each  type  of  fracture.  The 
dressing  is  left  in  place  for  a  period  of  eight  to  fifteen 
days,  sometimes  longer  ;  in  fact,  after  such  an  opera- 
tion as  has  been  described,  asepsis  of  the  wound  is 
almost  invariable,  and  this  allows  of  everything  being 
left  in  place,  absolute  immobility  being  ensured  ;  when 
the  gauze  is  removed,  a  healthy  surface  is  found, 
oozing  blood,  and  at  the  bottom  of  the  wound,  a  per- 
fect granulating  membrane  formed  from  the  layer 
of  periosteum.  The  dressing  is  repeated  with  aseptic 
gauze,  gently  introduced  into  the  wound,  and  is 
allowed  to  remain  in  place  there  for  a  further  ten  days. 
After  three  or  four  dressings,  the  onset  of  consolida- 
tion may  be  expected. 

This  process,  following  on  well-performed  sub- 
periosteal esquUlectomy  giving  normal  results,  occupies 
from  thirty  to  sixty  days  according  to  the  region  in- 
volved. The  bone  is  often  solid  before  healing  of  the 
superficial  wound  is  complete.  But  the  course  taken 
by  this  aseptic  wound  is  so  simple  that  I  see  no  great 
advantage  in  closing  it  by  sutures. 

Little  modification  is  required  by  a  septic  condi- 
tion of  the  wound :  if  the  soft  parts  are  seriously 
infected,  swollen,  and  oedematous,  I  prefer  a  dressing 
of  moist  gauze,  soaked  in  concentrated  saline  (10% 
to  14%),  to  a  dry  dressing.  This  should  be  left  in 
place  for  two  or  three  days  ;  it  produces  profuse 
suppuration,  the  pus  being  of  a  greenish-yellow  colour. 
"When  it  is  removed,  whitish  patches  will  be  found 
scattered  over  the  granulations  ;  this  organic  debris 
is  removed  with  a  swab  or  forceps,  and  the  wound 
is  well  dried  and  treated  by  heliotherapy,  or  by  a 
stream  of  hot  air.  Under  the  action  of  the  sun,  the 
wound  becomes  glazed,  then  bright  red^  and  oozes  a 


GENERAL  PRINCIPLES  IN  TREATMENT  351 


considerable  amount  of  lymph,  as  I  mentioned  in 
connection  with  wounds  after  articular  resection  (see 
l^art  I,  p.  29),  submitted  to  the  action  of  the  sun. 
With  hot  air  the  effects  are  the  same,  but  slightly 
less  pronounced.  A  second  moist  saline  dressing  is 
kept  applied  for  a  further  two  days,  after  which  it  is 
generally  possible  to  resort  finally  to  aseptic  gauze 
dressings,  aeration,  heliotherapy,  and  hot  air. 

I  shall  not  discuss  further  the  advantages  of  sys- 
tematically employing  physical  agents  in  the  restora- 
tive   treatment    of    wounds  :       I    emphasised    them 
sufficiently   in   Part  I.      I    merely 
repeat  that  aeration,  heliotherapy, 
and  the  hot-air  douche  are  to  me 
a  fundamental  feature  in  the  treat- 
ment of  all  gunshot  wounds,  and 
that  up  to  the  present  we  have  no 
more  effective  means  than  the  sun 
for    reducing    the    severity   of     a 
wound  and  accelerating  its  spon- 
taneous healing. 

The  formation  of  the  callus 
should  always  be  watched  hy  means 
of  X-rays  :  several  radiographs  are 
necessary  for  verification,  particu- 
larly after  comparatively  late 
secondary  operations  :  in  these 
cases  the  edges  of  the  wound  are 
sometimes  seen  to  have  become 
cedematous,  and  some  thick  pus  appears,  particularly 
if  the  ends  of  the  shaft  have  been  trimmed  with  a 
saw ;  a  radiograph  of  the  fracture  at  this  period  reveals 
a  small  notch  on  the  edge  of  the  shaft ;  this  is  a  small 
sequestrum  which  has  just  become  detached,  and  its 
removal  by  forceps  is  sufficient  to  clear  up  this  slight 
complication,  which  could  have  been  anticipated  if 
the  progress  of  the  fracture  had  been  watched  by 
X-rays,  and  the  successive  stages  in  the  formation  of 


Fig,  32. — Annular 
sequestrum  from  the 
end  of  the  shaft  of 
the  femur,  removed 
af tef  two  and  a  half 
months,  in  a  case  in 
which  esquillectomy 
had  been  performed 
at  the  front. 


352  TREATMENT   OF   FRACTURES 

a  callus  followed  by  this  means.  If  the  treatment  is 
carried  out  in  this  way,  none  of  the  complications  by 
infection,  of  which  so  many  surgeons  speak,  will 
occur  :  far-reaching  tracks  of  pus  will  not  develop, 
neither  will  associated  arthritis,  lymphangitis,  nor 
secondary  haemorrhage.  Progress  will  be  simple  from 
first  to  last,  and  cure  will  be  effected  without  a  trace 
of  the  troublesome  sequelae  which  for  years  afflict 
the  unfortunate  men  whose  wounds  their  surgeons 
have  not  desired  or  dared  to  disinfect  early  and  com- 
pletely. 

It  is  often  surprising,  particularly  after  a  total 
secondary  esquillectomy,  to  note  the  rapidity  with 
which  the  callus  forms.  I  mentioned  on  p.  32()  cer- 
tain statistics  which  will  undoubtedly  appear  exag- 
gerated to  some.  They  are,  however,  absolutely 
exact. 

But  it  should  be  added  that  a  callus  formed  in  so 
short  a  time  is  not  very  hard,  and  that  immobilisation 
should  be  continued  for  a  long  period  after  consolida- 
tion has  been  ascertained.  Recently  in  a  case  in 
which  I  performed  a  secondary  esquillectomy  for  a 
sub-trochanteric  fracture,  in  which  the  limb  could  be 
raised  on  the  forty-second  day,  the  callus  became 
bent  between  the  seventieth  and  eightieth  days,  the 
extension  having  been  removed  on  the  sixty-second 
day,  and  the  patient  having  left  his  bed  and  walked 
at  about  the  sixty-fifth.  I  applied  extension  on  the 
ninety-third  day,  and  succeeded  by  the  use  of  weights 
(7  to  8  kilos)  in  correcting  it  almost  completely. 

There  should  therefore  be  considerable  delay  betore 
free  use  of  the  limb  is  allowed  :  sixty  days  at  least  for 
the  upper  limb  and  120  for  the  lower  limb.  I  shall 
resume  this  subject  in  connection  with  particular 
fractures. 


GENERAL  PRINCIPLES  IN  TREATMENT    353 

II.   The  Reduction  of  Gunshot  Fractures 

Reduction  in  these  cases  is  not,  so  to  speak,  a  dis- 
tinct operation,  the  result  of  co-ordinated  movements 
such  as  are  carried  out  for  simple  fracture  of  the  radius, 
or  for  Dupuytren's  fracture,  for  instance.  The  multi- 
plicity of  fragments .  and  splinters,  the  incalculable 
element  introduced  by  muscular  laceration  and  the 
irregularity  of  the  area  affected,  render  this  impossible  ; 
and  when  there  is  definite  over-riding,  as  in  fractures 
of  the  upper  part  of  the  femur  and  humerus,  the 
muscular  force  to  be  overcome  is  such  that  the  most 
vigorous  movements  at  the  time  cannot  reduce  them. 
After  such  wide  clearance  as  has  been  described,  the 
matter  is  different  :  reduction  is  almost  always  prac- 
tically realised  when  the  operation  is  over,  or,  at  least, 
it  is  very  much  facilitated;  frequently  it  consists 
simply  in  immobilising  the  limb  in  the  physiologically 
correct  position ;  in  any  case,  prolonged  extension 
always  gives  the  result  desired. 

In  theory,  three  methods  of  reduction  may  be 
employed  : 

Reduction  by  open  operation  (fixation  by  plating, 
etc.), 

Rapid  reduction  by  manipulation. 

Slow  reduction  by  continued  extension. 

1.  Reduction  BY  OPEN  OPERATION. — The  invariably 
septic  condition  of  all  gunshot  wounds  absolutely 
forbids  reduction  by  this  method  as  practised  by 
Lambotte  and  Lane  in  the  simple  fractures  of  civil 
practice  ;  attempts  should  not  be  made  to  restore 
large  fragments  and  splinters  to  their  original  position, 
supporting  the  whole  by  metallic  apparatus  (bronze 
wire,  clasps,  or  plates).  Certain  surgeons  may  have 
been  tempted  to  do  this  at  the  beginning  of  the  w^ar, 
on  examining  a  fresh  wound  during  the  first  few 
hours,  before  any  signs  had  appeared  of  the  serious 
infection    which   was    developing   there.     The    rapid 


354         TREATMENT   OF   FRACTURES 

appearance  of  dangerous  septic  conditions  has  abso- 
lutely and  finally  barred  .tlie  renewal  of  such  attempts  : 
in  some  cases  sepsis  was  fatal,  others  had  to  be  ampu- 
tated, in  others  widespread  necrosis  of  bone  occurred. 
I  have  seen  shocking  examples  of  the  latter  at  medical 
boards. 

On  the  other  hand,  it  is  quite  conceivable  that  after 
free  preventive  esquillectomy,  this  method  of  reduc- 
tion might  appear  tempting  :  it  is  so  simple  to  use  a 
plate  or  wire  to  unite  the  two  contiguous  ends  of  the 
shaft,  when  the  injured  region,  its  surfaces  made  plain, 
cleared  of  all  infecting  debris  and  all  its  splinters,  is 
clean  and  uncomplicated. 

I  am  persuaded  that  this  could  be  attempted  with 
frequent,  if  not  constant,  success  on  the  single  con- 
dition of  keeping  the  wound  widely  open  and  dressing 
the  osseous  region  itself  without  obstacle.  Although 
never  having  actually  done  this,  with  my  experience 
of  the  progress  of  fractures  after  free  esquillectomy, 
I  shall  not  hesitate  to  attempt  it  under  favourable 
conditions  in  regard  to  supervision  and  apparatus. 

But  in  practice,  this  reduction  with  immediate  re- 
union of  the  bones  by  osteosynthesis  is  not  advisable 
and  should  not  be  made  a  routine  procedure  :  war 
surgery  should  before  all  things  be  safe  surgery  ;  every 
case  should  be  enabled  as  soon  as  possible  to  be  evacu- 
ated without  danger ;  a  minimum  of  supervision 
should  be  required,  for  it  is  possible  that  the  patient 
cannot  be  closely  observed  ;  an  operation  case,  during 
the  hours  following  the  operation,  may  be  finally 
separated  from  the  surgeon  and  sent  on  a  long  journey. 
Artificial  union  of  bone,  even  under  the  aseptic  con- 
ditions which  I  admitted  in  theory  above,  may  prove, 
if  the  operation  is  not  absolutely  complete  (which  is 
always  possible),  to  be  the  origin  of  serious  complica- 
tions which  must  not  be  risked  in  the  case  of  wounded 
men  :  it  may  only  be  attempted  when  the  operation 
takes  place  in  the  earliest  stages,  and  when  constant 


GENERAL  PRINCIPLES  IN  TREATMENT    355 

and  prolonged  supervision  is  assured  for  the  patient. 
In  any  other  circumstances,  it  should  not  be  per- 
formed on  any  account. 

It  also  possesses  the  disadvantage  of  perpetuating 
the  shortening  when  a  reduction  of  the  interfrag- 
mentary space  has  occurred,  assuming  that  periosteal 
proliferation  succeeds  in  filling  the  gap.  Finally,  it  is 
unnecessary :  free  esquillectomy,  such  as  should  be 
practised,  simplifies  the  region  of  fracture  to  such  an 
extent,  that  reduction  itself  is  realised  by  it  :  it  is 
enough  to  immobilise  in  good  position  to  ensure  auto- 
matic reduction,  or  an  easy  realisation  of  it  with  the 
help  of  continuous  extension. 

Briefly,  sub-periosteal  esquillectomy  is  the  best  opera- 
tive method  of  initiating  a  good  reduction. 

2.  Rapid  and  forcible  reduction. — This  consists 
in  restoring  the  correct  position  of  the  fragments  by  a 
single  effort  by  means  of  powerful  traction  and  suit- 
able manipulations.  This  is  very  easy  in  certain 
regions,  when  the  fracture  has  been  widely  cleared ; 
it  is,  on  the  contrary,  very  difficult,  sometimes  impos- 
sible, whenever  the  fragments  have  been  left  in 
place  and  some  are  laterally  displaced,  as  is  usually 
the  case.  Marked  displacement  is  the  result  of 
strong  muscular  action  which  can  only  be  overcome 
with  difficulty  under  an  anaesthetic,  and  much  less 
without  it. 

Immediate  reduction  may  be  attempted  in  two 
ways,  either  by  means  of  manual  or  instrumental 
means  followed  by  the  immediate  application  of  im- 
mobilisation apparatus,  or  by  immobilising  apparatus 
with  adjustable  springs  which  apply  rapid  extension 
and  correct  the  displacement  at  once. 

In  the  former  case  (taking  as  an  example  a  frac- 
tured thigh),  an  attempt  is  made,  under  an  anaesthetic, 
by  traction  in  a  definite  direction,  to  bring  end  to  end 
the  two  fragments  of  the  shaft ;  when  this  is  effected, 
they  are  fixed  in  position  by  a  large  immobilising 


356  TREATMENT   OF   FRACTURES 

plaster  casing  applied  while  the  pull  is  being 
exerted,  and  only  removed  after  consolidation  has 
occurred. 

In  the  latter,  Delbet's  apparatus  is  used  for  a  frac- 
tured thigh.  This  appliance,  which  will  be  described 
later,  gives  very  powerful  extension,  and  reduces 
serious  displacements  in  a  few  seconds. 

But  sudden  reduction  is  often  painful ;  frequently 
it  is  scarcely  bearable  unless  it  merely  attempts  to 
place  the  lower  fragment  in  line  with  the  upper, 
pending  immobilisation  of  the  limb  (as  in  supination 
of  the  hand  in  fractures  of  the  forearm)  ;  further,  it 
does  not  always  give  accurate  results,  as  is  proved  by 
X-rays,  and  in  the  main  there  is  every  advantage  in 
the  slower  method  by  continuous  extension.  This  is 
so  true  that  Alquier,  the  surgeon  who  has  perhaps  had 
the  most  experience  of  Delbet's  apparatus,  has  com- 
pletely given  up  rapid  reduction. 

Immediate  reduction  is  only  demanded  by  one  cir- 
cumstance ;  the  improvised  application  of  a  temporary 
apparatus  for  transport  when  a  rapid  evacuation  is 
expected,  ^or  it  is  important  to  immobilise  after  as 
perfect  a  reduction  as  possible.  But  absolute  con- 
fidence should  not  be  placed  in  the  results  apparently 
obtained,  and  when  the  transference  of  the  patient 
has  been  effected,  the  original  apparatus  should  not 
be  retained  permanently  unless  it  is  shown  by  X-rays 
that  the  desired  reduction  has  been  obtained.  This 
is  unusual,  and  as  a  rule  it  is  better  to  resort  to  pro- 
gressive reduction  by  continued  extension,  a  slow  and 
gentle,  but  sure,  method. 

3.  Gradual  reduction. — This  is  the  preferable 
method :  the  ceaseless  action  of  continued  extension 
has  a  marvellous  reducing  action,  giving  no  pain  and 
abolishing  muscular  contraction,  which  obliges  the 
bones  to  resume  their  original  positions,  restores 
structures  to  their  normal  relations,  and  thus  enor- 
mously favours  drainage  and  repair. 


GENERAL  PRINCIPLES  IN  TREATMENT  357 

It  is  advisable  in  any  region,  and  can  only  be  wholly 
dispensed  with  in  the  forearm. 

It  can  be  produced  in  different  ways  : 

[a)  Continuous  extension  by  Weights. — The  usual 
procedure  is  an  extension  by  weights  fixed  to  a  stirrup 
applied  to  the  limb  by  adhesive  plaster,  or  by  an 
adjustable  screw  pulling  on  the  stirrup  itself.  The 
traction  is  exerted  on  the  lower  fragment  through 
these  bands  and  the  soft  parts.  It  is  of  advantage  to 
apply  the  stirrup,  when  possible,  to  the  whole  length 
of  the  limb  as  far  as  the  groin  or  axilla,  wherever  the 
fracture  may  be  situated,  but  unfortunately  the  exis- 
tence of  wounds  is  often  an  obstacle  to  this.  The 
strips  employed  should  preferably  be  adhesive,* 
applied  directly  to  the  shaved  skin ;  they  should  be 
applied  over  as  wide  an  area  and  as  high  up  the  limb 
{i:e.  leg,  thigh,  arm,  or  forearm)  as  possible,  in  order 
that  the  circular  or  overlapping  strips  that  fasten 
parallel  ones  to  the  skin  may  not  slip  down  enough  to 
cut  into  the  skin  just  above  the  joint  below,  which 
is  extremely  painful,  particularly  at  the  knee. 

The  strips  to  form  the  stirrup  are  piit  on  parallel 
to  the  limb,  and  made  fast  by  others  wound  spirally 
round  it.  The  tension  is  distributed  in  this  way, 
which  is  preferable  to  winding  only  two  or  three  turns, 
which  rapidly  become  painful.  On  the  other  hand, 
they  should  approach  as  near  as  possible  to  the  region 
of  the  fracture.     If  possible,  there  should  not  be  a 

*  Failing  leucoplast,  and  in  place  of  the  old  diachylon  (lead) 
plaster,  different  adhesive  substances  may  be  used,  liquefied  by 
warming  in  a  water-bath,  and  applied  to  the  strips  of  bandage. 
Amongst  the  very  numerous  formulae  which  exist,  the  following 
has  beep  recommended  : 

Rosin  (colophane)  .  .  .50  granuhes 

90  per  cent,  alcohol  .  .  .     50         ,, 

Venice  turpentine  .  .  .5         ,, 

Benzine      .          .  .  .  .     25        ,, 

This  is  spread  over  the  limb  with  a  brush,  and  extension  bands 
of  calico  are  laid  down  upon  the  skin.  I  have  had  no  experience 
of  this  method. 


358  TREATMENT   OF   FRACTURES 

joint  interposed  between  the  point  of  application  of 
the  force  and  the  bone  upon  which  it  is  to  act.  It  is 
wrong  to  exert  traction  on  the  leg  in  order  to  pull 
on  the  femur,  since  this  permanently  upsets  the  knee, 
causing  terrible  difficulties  in  the  ■  future.  Traction 
should  be  exerted  in  a  definite  direction  suited  to  the 
particular  case  :  it  should  always  be  exerted  in  a  line 
with  the  upper  fragment,  which  is  differently  acted 
upon  by  the  muscles,  according  to  the  height  of  the 
fracture  :  thus,  for  instance,  the  lower  fragment  of 
the  humerus  or  femur  should  be  abducted  in  fractures 
situated  slightly  above  the  middle  of  the  shaft. 

There  is  one  further  remark  to  make  on  the  subject 
of  continuous  extension  by  weights  :  permanent  trac- 
tion is  more  efficacious  when  exerted  on  parts  of  limbs 
whose  muscles  are  relaxed.  The  relaxed  position  in 
the  upper  limb  is  that  of  semi-flexion  of  the  elbow 
and  pronation ;  in  the  lower  limb,  semi-flexion  at 
the  ankle,  knee,  and  hip.  These  positions  should  be 
utilised,  since  continuous  extension  is  more  easily 
tolerated  and  more  efficacious  when  these  physiological 
considerations  have  been  taken  into  account.  This 
is  of  great  importance  in  fractures  of  the  thigh. 

Continuous  extension  by  weights,  based  on  these 
theories,  is  the  best  method  of  reducing  fractures,  and 
should  be  employed  for  preference.  It  has  also  the 
inestimable  advantage  over  all  other  methods  of  being 
easily  applicable  anywhere,  and  by  very  simple  means, 
which  in  war  surgery  is  an  essential  point. 

Continuous  extension  by  weights  may  also  be  estab- 
lished by  means  of  a  laced  boot  or  plaster  gaiter,  on 
the  plantar  surface  of  which  a  small  ring  is  fixed  for 
traction.  But  a  plaster  gaiter  is  often  painful,  and 
such  means  have  the  further  disadvantage,  if  they 
are  employed  for  fractures  of  the  thigh,  as  is  usually 
the  case,  of  exerting  the  pull  from  too  great  a  distance, 
stretching  the  knee  which  is  already  distended  by 
slight  hydrarthrosis. 


QENEEAL  PRINCIPLES  IN  TREATMENT    359 

(6)  Extension  by  a  transfixion  Nail  or  metallic 
Loop. — A  more  precise,  or  at  least  more  direct,  method, 
is  that  of  extension  by  means  of  a  nail,  the  latter 
transfixing  either  the  femoral  condyles  or  the  os  calcis. 
Many  surgeons  are  quite  reasonably  not  attracted  by 
the  idea  of  transfixing  a  bone.  But  in  spite  of  its 
disadvantages,  if  the  method  gives  better  results  than 
others,  there  is  no  reason  for  hesitation  in  adopting 
it.  Those  who  have  employed  it  say  that  the  method 
is  painless  and  safe,  and  brings  about  reduction  of 
the  most  serious  displacements.  I  have  had  occasion 
to  examine  several  cases  which  had  been  treated  in 
this  way  for  fractures  of  the  thigh.  The  results  were 
very  mediocre  :  there  were  shortenings  of  from  2^ 
to  3  inches,  and  X-rays  showed  considerable  over- 
riding which  had  not  been  corrected  at  all. 

On  the  other  hand,  if  the  fracture  is  carefully 
cleared  by  free  esquillectomy,  reduction  is  easily 
obtained  by  continuous  extension  on  ordinary  lines, 
always  provided  that  it  is  applied  in  the  right  direc- 
tion. During  twenty  months  of  war,  I  have  not  yet 
seen  a  fracture  which  I  could  not  reduce  satisfactorily 
by  the  usual  methods.  But  it  is  obvious  that  all 
these  methods  will  fail  if  the  line  of  traction  does  not 
correspond  with  that  of  the  upper  fragment. 

I  see,  therefore,  no  necessity  for  extension  by  means 
of  a  nail ;  it  uselessly  complicates  the  treatment,  and 
should  never  be  employed. 

Is  this  also  true  of  Finochietto's  modification  which 
Chutro  has  recently  introduced  into  France  for  frac- 
tures of  the  thigh  ? 

This  method  consists  in  passing  a  strip  of  metal 
over  the  upper  surface  of  the  os  calcis  in  front  of  the 
tendo  Achillis.  A  metal  stirrup,  through  which  trac- 
tion is  exerted,  is  fixed  to  this  strip  (figs.  33,  34,  35). 
It  may  be  left  in  place  for  some  weeks  without  incon- 
venience. 

Finochietto's  stirrup  is  a  decided  improvement  on 


3()0         TREATMENT   OF   FRACTURES 

extension  by  means  of  a  nail ;  it  is  a  refinement  of 
what  some  surgeons  have  done  by  fixing  a  simple 
loop  of  wire  in  the  same  position  ;  theoretically,  the 
same  objection  applies  to  it  as  to  other  methods  of 
traction  from  a  distance — it  pulls  on  the  leg  and 
thus  tends  to  produce  disturbance  at  the  knee.  Chutro 
and  Heitz-Boyer  assert  that  the  extension  is  perfect, 
and  produces  no  such  undesirable-  effect.  This  should 
therefore  be  a  procedure  to  hold  in  reserve,  and  to 
utilise  if  it  is  actually  proved  that  after  powerful 
traction  the  knee  is  not  dislocated,  for  a  fixed  joint  is 
preferable  to  a  flail  one. 

Lastly,  the  extending  force  may  be  exerted  by 
elastic  traction.  This  is  only  used  exceptionally ; 
apart  from  the  appliance  for  fractures  of  the  thigh  (to 
be  described  later),  invented  and  used  by  Sencert,  I 
know  of  no  example  of  it. 

The  weights  may  be  replaced  by  an  adjustable 
screw  apparatus  which  easily  gives  very  powerful 
continuous  extension. 

(c)  Extension  by  sliding  or  spring  Appliances.- — There 
is  an  entirely  different  type  of  appliance  in  which  con- 
tinuous extension  is  produced  by  springs,  and  by 
shafts  sliding  one  over  the  other,  adjusted  by  some 
kind  of  mechanism. 

The  typical  appliance  of  this  type  is  that  of  Pierre 
Delbet,  in  which  extension  is  obtained  by  means  of  a 
flanged  spring  which  forces  apart  two  shafts  which 
slide  in  a  tube  and  are  each  connected  with  and  act 
on  the  limb,  the  one  above,  and  the  other  below,  the 
fracture  :  above  on  the  axilla,  for  instance,  and  below 
on  the  forearm,  which  is  kept  flexed  at  right  angles 
by  means  of  a  sling. 

Many  excellent  appliances  of  different  kinds  have 
been  invented  on  this  ingenious  and  practical  model. 
Usually  they  consist  of  two  plaster  collars  of  varying 
length,  incorporated  with  two  hollow  shafts  sliding 
one  over  the  other  and  enclosing  a  spring  which  tends 


GENERAL  PRINCIPLES  IN  TREATMENT    3f5l 


continually  to  separate  the  two  resisting  points,  that 
is,  the  two  plaster  collars ;  the  latter  by  means  of  the 
sliding  concentric  shafts  and  the  pressure  thus  con- 


?55;„. 


i,''^-^:-'-^: 


^-^^-^^mw^m 


Fig.  33. — Metallic  strip  and  its  guide  (Pedro  Chutro). 


Fig,  34,— Position  of  the 
metal  strip  in  relation  to  bone 
and  tendons  (Pedro  Chutro). 


Fig.  35, — The  apparatus  in 
place  (Pedro  Chutro). 


tinuously   applied   to   the   lower    collar   submit   the 
limb  to  permanent  extension. 

It  will  be  seen  that  a  large  number  of  appliances 


362  TREATMENT    OF   FRACTURES 

exist  for  producing  continuous  extension  in  fractures. 
All  can  give  and  have  given  good  results,  for  what  is 
of  more  importance  than  the  variety  of  appliance 
used  is  the  sound  application  of  the  fundamental 
principle  on  which  all  are  based  ;  the  technical  method 
is  a  matter  of  convenience,  and  its  importance  is 
secondary. 

As  it  is  very  difficult  to  choose  between  the  numerous 
procedures  recommended,  I  shall  discuss  in  connec- 
tion with  each  fracture  the  appliances  which  I  use, 
without  even  alluding  to  those  of  which  I  have  no 
experience  ;  this  does  not  mean  that  they  are  faulty, 
or  should  be  rejected. 

Lastly,  after  free  esquillectomy  ^permitting  of  infre- 
quent dressi7ig,  the  question  of  apparatus  is  much  sim- 
plified, since  the  progress  is  clinically  aseptic,  and  it 
is  usually  necessary  only  to  dress  the  wound  at  long 
intervals. 

ni.   The  Immobilisation  of  Fractures 

All  fractures  should  be  immobilised  for  a  long 
period.  It  is  too  often  forgotten  that  immobilisation 
is  at  the  root  of  all  treatment  directed  against  infec- 
tion :  without  it,  the  injured  area  is  constantly  sub- 
ject to  further  trauma,  further  infection  of  the  wound 
is  continually  being  produced,  great  increase  in  the 
virulen(5e  of  the  infection  being  the  result.  For  this 
reason  it  may  be  said  that  immobilisation  is  a  prime 
necessity  of  disinfective  treatment ;  it  is  also  indis- 
pensable for  avoiding  pain,  and  for  maintaining 
reduction,  thus  favouring  the  formation  of  the  callus. 

Theoretically  the  best  method  of  immobilising  a 
fracture  consists  in  uniting  the  fragments,  either  by 
wiring,  a  plate  (Lambotte),  or  by  a  clamp  of  the  type 
devised  by  Dujarier. 

This  operative  fixation  of  the  fracture,  however,  is 
rarely,  and  should  not  be  generally,  employed.     At- 


GENERAL  PRINCIPLES  IN  TREATMENT  m:^ 

tempted  indiscriminately,  at  the  beginning  of  the 
war,  by  surgeons  to  whom  the  constant  infection  of 
gunshot  fractures  was  unknown,  it  brought  disaster 
and  was  condemned.  It  might,  however,  perhaps  be 
excellent  in  certain  cases,  after  careful  operative 
disinfection  and  free  sub-periosteal  esquillectomy,  if 
the  object  were  merely  to  produce  provisional  union 
of  the  bones,  and  the  wound  were  kept  open.  But  it 
should  not  be  supposed  that  this  primary  osteosyn- 
thesis after  sub-periosteal  esquillectomy  is  applicable 
under  all  conditions  and  to  all  cases.  Useful  and 
beneficial  if  operative  disinfection  has  been  complete, 
it  becomes  dangerous  if  some  overlooked  debris  threa- 
tens to  provoke  the  development  of  acute  osteitis. 
It  should  also  only  be  attempted  in  cases  operated  on 
early,  by  a  trained  surgeon  who  is  certain  of  being 
able  to  look  after  the  case  for  a  long  period. 

Further,  all  cases  in  the  above  categories  do  not 
justify  it.  It  might  be  indicated  in  all  aseptic  frac- 
tures in  which,  after  sub-periosteal  esquillectomy, 
only  two  pointed  extremities  of  the  shaft  remain, 
meeting  at  their  apex  ;  it  would  then  be  easy  and 
useful  to  unite  the  two  fragments  by  a  Lambotte  plate. 
But  when,  on  the  other  hand,  clearance  has  given  rise 
to  extensive  loss  of  bone,  and  a  fairly  large  interfrag- 
mentary space,  osteosynthesis  is  not  advisable,  since 
it  would  cause  too  great  a  shortening,  whereas  a 
periosteal  callus,  filling  the  interfragmentary  space, 
will  unite  the  two  extremities  of  the  bone  with  very 
trivial  diminution  in  length. 

When  it  is  added  that  it  is  not  without  danger  in 
infected  fractures,  it  will  be  agreed  that  it  is  only 
advisable  in  exceptional  instances. 

Lastly,  operative  fixation  cannot  suffice  in  itself  ; 
it  must  always  be  reinforced  by  an  immobilisation 
appliance.  This  consideration  decidedly  reduces  its 
value. 

Initial  fixation  by  metal  is  therefore  likely  to  re- 


364  TREATMENT    OF    FRACTURES 

main  an  unusual  method  *  at  the  front,  and  recourse 
should  be  had  usually  to  the  indirect  methods  of 
immobilisation.  The  latter  are  numerous,  many  are 
excellent,  but  their  use  is  not  always  satisfactory, 
because  the  fundamental  rules  of  good  immobilisation 
are  not  understood,  because  sometimes  the  conviction 
of  its  necessity  is  not  sufficiently  strong,  and  lastly, 
because  there  is  sometimes  an  unjustified  conviction 
of  its  riskiness.  In  reality,  it  should  be  stated  as  a 
principle  that  such  a  thing  as  too  rigorously  or  too 
completely  immobilised  a  fracture  cannot  exist.  Im- 
mobilisation after  esquiUectomy  should  be  the  principal 
care  of  every  surgeon. 

A.  The  principles  governing  immobilisation. 

1.  The  principles  of  Bonnet. — Fixation  has  for 
a  long  time  been  a  difficult  problem  to  all  who  have 
not  paid  the  closest  attention  to  the  early  disinfection 
of  fractures  ;  they  have  continually  to  fight  suppura- 
tion, and  hence  are  compelled  to  dress  the  wounds  at 
least  once  daily,  they  have  to  watch  closely  the  spread 
of  infection,  to  make  complicated  and  repeated  ar- 
rangements for  drainage,  to  carry  out  secondary 
esquillectomies,  and  to  irrigate  freely  with  antiseptics 
in  order  to  sweep  out  necrosed  organic  debris.  Sup- 
puration prevents  the  accurate  adjustment  of  any 
fixation  appliance  ;  dressing  is  difficult  and  painful  ; 
continuous  friction  between  the  opposed  fractured 
surfaces  results  in  numerous  small  local  injuries  which 
promote  infection,  thereby  interfering  with  disinfec- 
tion and  repair. 

Attempts   were   made   to   abolish   these   disadvan- 

*  While  correcting  the  proofs  of  this  book,  I  received  two  cases 
in  which  the  large  splinters  had  been  surrounded  by  a  wire  suture. 
After  three  months  there  was  no  consolidation,  and  the  wire  gave 
rise  to  a  permanent  sinus.  I  removed  the  wire,  and  consolidation 
occurred  soon  afterwards,  but  the  fragments  were  necrosed  and 
had  to  be  removed.  After  eight  months,  these  patients  have  not 
yet  recovered.     There  was  therefore  no  advantage  in  the  method. 


GENERAL  PRINCIPLES  IN  TREATMENT  365 

tages  by  reintroducing  the  interrupted  plaster  casing, 
a  large  number  of  which  were  badly  conceived  and 
violated  the  fundamental  principles  of  fixation.  By 
continually  evolving  new  appliances,  some  very  in- 
genious solutions  have  been  found  in  spite  of  very 
real  difficulties,  and  some  of  these  innovations  will 
live  in  surgical  therapeutics,  but  this  was  approaching 
the  problem  from  the  wrong  side  :  the  only  method  of 
simplifying  dressings,  and  of  rendering  them  painless 
and  harmless,  is  to  disinfect  the  area  of  the  fracture  at 
the  outset,  and  thereby  avoid  suppuration  in  it.  It 
then  becomes  much  easier  to  arrange  for  an  ideal 
immobilisation,  and  above  all,  nothing  then  interferes 
with  its  maintenance. 

The  only  ideal  immobilisation  is  that  which  fixes  the 
extremities  of  the  bone  exactly  in  a  definite  position, 
without  possibility  of  displacement  in  the  region  of  the 
fracture,  and  without  causing  pain  to  the  patient. 

That  this  may  be  so,  to  follow  the  classical  and 
often  misunderstood  principles  of  A.  Bonnet,  the 
articulations  above  and  below  the  fracture  must  be  im- 
mobilised, that  is  to  say,  the  whole  limb  must  be 
immobilised. 

This  fixation,  which  must  be  maintained  until  con- 
solidation has  occurred,  must  be  as  rigorous  at  the 
beginning  as  at  the  end — -at  the  beginning,  to  avoid 
pain  and  contribute  by  rest  to  the  disappearance 
of  infection  ;  at  the  end,  when  the  callus  is  about  to 
form,  in  order  that  the  new  bone  may  assume  a  cor- 
rect shape  and  that  there  may  be  no  deformity  of  the 
limb. 

But  immobilisation  thus  understood  has  the  dis- 
advantage, according  to  its  own  principles,  of  fixing 
the  neighbouring  joiats.  This  is  of  little  importance 
if  it  is  not  maintained  too  long  ;  if,  on  the  other  hand 
it  be  prolonged,  muscles  atrophy,  joints  stiffen  and 
when  at  length  the  bones  have  united,  the  functions  of 
the  limb  have  been  impaired  as  a  direct  result  of  the 


366         TREATMENT   OF    FRACTURES 

immobilisation.  The  result  is  therefore  far  from 
being  perfect. 

As  a  matter  of  fact,  when  he  was  studying  im- 
mobilisation and  formulated  the  rules  which  the  entire 
world  has  adopted,  Bonnet  had  only  articular  path- 
ology in  view,  and  did  not  consider  fractures.  It  is 
certain  that,  to  immobilise  a  joint,  the  two  epiphyses 
forming  it  must  be  fixed.  Now  these  cannot  be  main- 
tained in  complete  repose  unless  all  movement  is 
suppressed  in  the  epiphysis  of  the  other  end  of  the 
bone,  the  slightest  displacement  of  which  reacts  on 
the  opposite  end  of  the  lever  {i.e.  of  the  shaft).  This 
amounts  to  stating  that  the  whole  joint  must  be 
immobilised,  and  no  other  solution  but  that  of  A. 
Bonnet  is  possible.  But  in  shaft  fractures  the  case  is 
different,  and  for  these  the  problem  may  be  studied 
differently,  an  attempt  being  made  to  give  the  joints 
free  play. 

2.  New  principles  for  the  immobilisation  of 
FRACTURES. — ^As  a  matter  of  fact,  if  the  circumstances 
are  pictured,  it  becomes  evident  that,  to  immobilise 
a  fracture,  there  is  no  need  to  fix  the  joints  above  and 
below  it :  it  is  enough  to  fix  the  fragments  concerned 
in  the  desired  position  by  means  of  a  metal  shaft 
taking  purchase  against  the  projections  of  the  corre- 
sponding epiphyses,  or  on  the  soft  parts  surrounding 
them,  that  is,  above  and  below  the  joints  situated 
below  and  above  the  seat  of  injury  respectively.  The 
theoretical  appliance  which  realises  this,  is  as  it  were  a 
form  of  external  prosthesis,  buttressed  against  the 
epiphyseal  projections,  closely  comparable,  in  fact,  to 
the  internal  prosthesis  represented  by  a  Lambotte 
plate.  After  this  the  neighbouring  joints  are  free, 
and  can  move,  if  not  normally,  at  least  enough  to 
preserve  their  flexibility.  Pierre  Delbet  succeeded  in 
reducing  this  to  practical  form,  evolving  appliances 
which  gave  extension  and  at  the  same  time  only  in- 
volved the   actual   segment   of  the  limb   concerned. 


GENERAL  PRINCIPLES  IN  TREATMENT  367 

leaving  the  neighbouring  joints  relatively  at  liberty- 
while  buttressing  close  to  them,  either  against  some 
lateral  support  (the  edge  of  the  axilla,  for  instance), 
of  which  use  is  made  in  the  case  of  spring  appliances, 
or  on  fixed  bony  points  of  support  utilised  by  means 
of  a  plaster  casing.  Descriptions  of  these  appliances 
will  be  given  later.  For  the  present  it  is  sufficient  to 
mention  an  ingenious  practical  realisation  of  the 
principles  stated  above. 

3.  The  pri^^ciple  of  sling  suspension. — This  solu- 
tion of  the  fixation  problem  which  certain  American 
surgeons  have  given,  is  entirely  different  and  even 
more  simple  :  it  is  really  a  paradoxical  solution,  since 
it  appears  to  suppress  immobilisation  itself,  or  at  least 
immobilising  appliances,  but  it  is  nevertheless  excel- 
lent. It  consists  in  placing  the  limb  in  a  kind  of 
hammock,  suspended  in  the  air  and  kept  in  position 
by  weights,  and  applying  continuous  extension  ;  the 
opposing  force  is  exerted  by  the  weight  of  the  elevated 
limb.  Fixation  is  due  to  the  fact  that  movement 
of  the  injured  region  is  only  possible  in  toto,  and 
cannot  occur  within  the  region.  This  form  is  excel- 
lent ;  it  possesses  the  advantage  of  preventing  all 
friction  due  to  local  muscular  contraction,  suspension 
abolishing  all  resistance  and  allowing  only  of  dis- 
placement in  toto  of  the  fractured  region  which  itself 
is  fixed  by  traction  and  counter-extension. 

In  fact,  fixation  in  space  is  realised  by  preventing 
transmission  of  the  forces  of  movement,  the  principle 
utilised  being  that  of  suspension  from  a  universal 
joint. 

B.  Means  of  securing  immobilisation. — There  are  three 
possible  methods  of  immobilising,  which  innumer- 
able appliances  have  been  designed  to  realise.  All 
can  be  employed,  but  each  is  indicated  by  particular 
conditions.  It  is  necessary  to  understand  their 
management  thoroughly,  not  only  their  instrumental, 
but  their  therapeutic  use. 


368         TREATMENT   OF    FRACTURES 

It  i3  this  that  I  shall  endeavour  to  explain  in  study- 
ing the  different  types  of  fixation  according  to  the 
principles  on  which  they  are  based. 

Later  I  shall  indicate  which  should  be  chosen  in  the 
case  of  any  given  fi*acture. 

1.  Fixation  according  to  the  classical  rules 
OF  A.  Bonnet. — This  is  the  classical  form,  which 
should  be  thoroughly  understood,  for  it  remains  the 
fundamental  method,  and  the  method  for  cases  of 
urgency  ;  ignorance  of  it  is  inexcusable.  Duriyig  an 
influx  of  cases,  it  is  the  only  possible  method  ;  during 
evacuation  it  is  the  only  advisable  method  ;  in  a  war  of 
movement,  no  other  can  be  eynployed. 

There  are  numerous  ways  of  arranging  it — that  is, 
of  immobilising  the  fracture  by  immobilising  the  whole 
limb,  but  they  are  very  far  from  being  of  equal 
value. 

{a)  Metal  splints. — Whether  made  of  iron  wire,  iron 
gauze,  or  aluminium,  these  are  convenient,  quickly 
applied,  and,  except  for  the  thigh,  furnish  an  excellent 
means  of  temporary  fixation  :  they  represent  material 
always  ready  at  hand  and  quickly  applied,  they  do 
not  alter  in  shape  or  become  foul,  and  they  can  be 
sterilised  by  flaming  at  each  dressing.  Delorme's 
models  in  aluminium  are  very  light,  and  do  not  inter- 
fere with  examination  by  X-rays. 

In  spite  of  such  qualities,  these  splints  are  never 
efficient  appliances ;  they  immobilise  only  indifferently, 
they  mould  themselves  to  the  contours  of  the  limb 
and  not  of  the  bones,  and  consequently  cannot  really 
maintain  a  reduction  ;  as  soon  as  the  padding  be- 
comes deranged  or  the  bandages  loosen,  they  no  longer 
immobilise  at  all.  Lastly,  they  do  not  effect  the 
continuous  extension  which  lies  at  the  root  of  the 
treatment  of  almost  all  fractures. 

Trough  splints  are  not  suitable  apparatus  for  treat- 
ment ;  they  are  only  te7nporary  and  provisional  appli- 
ances, and  shoidd  not  even  be  used  as  malceshijts  for  a 


GENERAL  PRINCIPLES  IN  TREATMENT    369 

journey  if  there  is  tifue  eno^igh  to  make  better  arrange- 
ments. 

(b)  Reed-hlind  material. — This  is  a  war  invention. 
It  was  first  used  in  the  form  of  a  sheath  for  rapid 
temporary  fixation  (Pauchet),  then  in  the  form  of 
splints  (Eynard),  and  finally  as  plaster-splints  (Eynard- 
Santy). 

Three  to  five  thicknesses  of  ordinary  reed- blind 
material,  3  inches  in  width,  are  superposed,  each 
surface  being  padded  with  a  layer  of  cotton-wool,  very 
useful  long  splints  being  obtained  in  this  way. 

For  fixation  of  the  lower  limb,  three  may  be  used  : 
one,  about  a  yard  in  length,  is  placed  posteriorly, 
beneath  the  leg,  bent  up  at  right  angles  to  follow  the 
outline  of  the  heel  :  two  others,  30  inches  long,  are 
placed  laterally,  one  on  each  side  of  the  leg.  The  whole 
thing  is  held  together  by  the  application  of  tarlatan 
bandages. 

When  the  thigh  and  hip  are  concerned,  it  is  w^ell 
to  use  thicker  splints,  consisting  of  four  or  five  thick- 
nesses of  material.  The  posterior  one,  bent  up  at  the 
heel,  is  from  52  to  60  inches  in  length,  reaching  as  high 
as  the  waist  and  taking  a  firm  purchase  there.  An 
external  lateral  splint  passes  from  the  heel  to  the  iliac 
crest,  and  on  the  internal  aspect  is  a  third  one,  its 
upper  extremity  heavily  padded ;  at  the  genito- 
crural  fold  this  takes  its  purchase  from  the  ischio- 
pubic  ramus.  Securely  fixed  by  a  large  spica  bandage, 
these  splints  can  be  made  in  a  few  minutes  to  form 
an  appliance  in  which  the  patient  suffers  no  pain  and 
which  offers  strong  resistance  to  movement. 

The  use  of  blind- material  is  equally  simple  and 
practical  in  the  upper  limb. 

If  the  forearm,  elbow,  or  lower  extremity  of  the 
arm  is  to  be  immobilised,  two  splints  2  inches  wide 
and  consisting  of  two  or  three  thicknesses  are  suffi- 
cient. Aftei  flexing  the  elbow  at  right  angles  and 
pronating  the  forearm,    a   postero-external   splint   is 


;^ro         TREATMENT   OF   FRACTURES 

first  fitted  to  the  extensor  asj^ect  of  the  limb,  after 
being  broken  at  the  elbow.  It  should  be  a  yard  in 
length,  passing  ujjwards  as  far  as  the  posterior  border 
of  the  axilla,  and  downwards  flush  with  the  ends  of 
the  fingers. 

A  second  shorter  (18  in.)  slip  is  j)laced  along  the 
flexor  aspect  after  being  suitably  bent. 

The  blind  splint  is  a  good  appliance  in  early  stages, 
but  it  possesses  the  disadvantage  of  being  fixed  by  the 
dressing  itself,  and  must  be  removed  whenever  the 
wound  is  to  be  exposed  ;  it  is  also  permeable  by 
secretions.  This  has  led  to  the  use  of  plastered  blind- 
material,  which  is  equally  manageable  and  at  the 
same  time  more  rigid  and  resistant. 

This  consists  of  a  form  of  casing  made  up  of  three 
or  four  thicknesses  of  material ;  this  casing  is  directly 
surrounded  by  two  thicknesses  of  stiffened  tarlatan, 
kept  in  place  by  a  few  stitches  ;  by  this  means  the 
splint,  dipped  into  liquid  plaster,  is  satisfactorily  im- 
pregnated, and  retains  sufficient  plaster  to  set  well. 
The  appliance  is  completed  by  plaster  bands  connect- 
ing the  splints  and  forming  a  certain  number  of  rings 
at  intervals.  After  this,  free  access  to  the  wound, 
and  supervision  of  the  injured  limb  in  its  entire  length, 
are  easy  matters. 

These  excellent  appliances  give  good  fixation  and 
are  easily  handled. 

(c)  Plaster  appliances. — Plaster  is  the  most  widely 
applicable  and  practical  method  of  immobilising  frac- 
tures :  it  meets  all  requirements,  and  is  so  convenient 
and  manageable  that  nothing  can  take  its  place. 
Certain  appliances  and  arrangements,  may,  in  a  given 
case,  be  more  comfortable  and  assure  a  better  result, 
but  if  there  were  to  be  only  one  procedure  for  treating 
fractures,  plaster  w^ould  certainly  be  chosen.  Happily, 
however,  this  is  not  the  case,  and  selection  is  possible. 
This  does  not  alter  the  fact  that  in  present-day  sur- 
gery, and  war-surgery  in  particular,  plaster  appliances, 


GENERAL  PRINCIPLES  IN  TREATMENT    371 

in  spite  of  certain  disadvantages,  remain  as  the  basis 
of  fracture  treatment.  Some  surgeons  criticise  them 
severely  ;  they  do  not,  however,  understand  their  use, 
for  it  is  a  definite  art.  A  good  plaster  should  not  give 
pain,  cause  ulceration,  or  grip  too  tightly,  and  should 
immobilise  thoroughly.     It  is  all  a  matter  of  care. 

Method  of  making  a  Plaster  casing. — There  are  two 
types  of  plaster  appliance,  troughs  and  circular  ban- 
dages. In  principle,  the  troughs  are  removable  and 
the  circular  bandages  are  not.  In  practice,  windows 
of  varying  size  are  left  in  the  circular  form,  and  the 
different  parts  are  connected  by  plaster  or  metal 
bands  ;  in  this  way  the  wound  is  left  exposed  as 
desired  so  completely  and  so  well  that  circular  plasters 
are  now  the  appliances  that  really  allow  of  convenient 
dressing,  troughs  no  longer  being  employed  except  for 
wounds  which  are  very  infrequently  dressed. 

In  any  case,  a  plaster  must  be  large,  and  moulded 
to  the  projections  of  the  limb.  By  "  large "  it  is 
meant  that  it  should  immobilise  the  two  adjacent 
joints  according  to  the  principles  of  Bonnet. 

The  appliance  should  not  be  directly  applied  to  the 
skin,  even  if  the  latter  has  been  shaved  and  greased. 
It  is  better  to  interpose  a  thin  layer  of  flannel,  gauze, 
or  a  few  turns  of  bandage  without  reversing.  It  is 
useless  to  pad  any  bony  projections  except  the  patella  ; 
it  is  better  to  model  the  plaster  round  them  with  the 
thumb,  and  not  on  them.  Ulceration  is  avoided  in  this 
way.  The  best  isolating  material  in  the  case  of  a 
trough  is  ordinary  paper,  rolled  about  the  dressing 
and  the  limb  when  the  plaster  casing  is  about  to  be 
applied. 

The  'plaster  which  should  be  used  is  plaster  of  Paris 
(modelling  plaster).  If  it  is  at  all  old  or  stale  its  pro- 
perties may  be  restored  by  heating  for  a  few  minutes. 
A  definite  quantity  (about  4  kilos)  is  required  for  a 
plaster  for  the  lower  limb.  It  is  often  well  to  mix 
it   in   two   successive  portions   in   two   neighbouring 


372  TREATMENT   OF   FRACTURES 

basins  if  a  complicated  appliance  in  several  pieces  is 
to  be  made. 

Dressed  tarlatan  (tarlatane  gommee)  is  the  vehicle 
of  the  plaster,  and  is  employed  in  the  form  of  ban- 
dages or  strips.  The  bandages,  which  can  easily  be 
made  in  the  hospital,  should  be  5  to  10  yards  long 
and  4  to  6  inches  broad.  They  are  prepared  for  use  by 
being  rolled  up  after  passage  through  a  basin  full  of 
dry  plaster,  or  by  rolling  them  with  one  hand,  while 
the  flat  of  the  other  spreads  the  plaster  over  the 
tarlatan,  which  lies  flat  on  the  table.  According  to 
Calot,  who  has  written  a  practical  book  on  plaster 
appliances,  full  of  useful  advice,  the  outcome  of  long 
experience,  about  2  oz.  of  plaster  are  required  for 
each  yard  of  tarlatan  6  inches  wide,  10  ounces  for 
5  yards  of  bandages.  When  about  to  be  used,  the 
plaster  bandage  is  plunged  into  a  basin  half  full  of 
slightly  warm  water  (not  saline).  It  is  ready  for  use 
when  air-bubbles  cease  rising,  i.e.  in  two  to  three 
minutes.  A  fresh  bandage  should  therefore  be  placed 
in  the  basin  after  one  to  two  minutes,  if  several  are 
to  be  used.  Excess  of  water  should  be  squeezed  out 
before  the  bandage  is  applied.  The  application  should 
begin  at  the  extremity  of  the  limb,  passing  upward 
towards  the  trunk,  in  order  to  avoid  initial  constric- 
tion of  the  veins. 

The  plaster  usually  sets  ten  minutes  after  its 
application  was  begun. 

The  turns  should  be  regular  and  without  reverses  ; 
the  left  hand  methodically  arranges  and  smooths  the 
bandage,  while  the  right  applies  it  by  simply  unroll- 
ing it  without  pulling  or  tightening  :  it  is  easy  to  pre- 
dict how  the  apparatus  will  be  tolerated  by  watching 
how  it  is  put  on. 

I  repeat  what  I  have  already  said  on  the  subject  of 
bony  projections  ;  the  thumb  should  be  carried  round 
them  so  as  to  model  the  bandage  closely  to  their  con- 
tours in  order  that   they   may   support   and  fix  the 


GENERAL  PRINCIPLES  IN  TREATMENT  373 

casing,  and  therefore  not  be  ulcerated  by  it.  If 
desired,  a  circular  plaster  may  be  cut  open  down  the 
long  axis  of  the  limb,  giving  two  halves  easily  removed 
and  reapplied. 

Trough  splints  are  made  with  tarlatan  slips  con- 
sisting of  eight  to  twelve  layers.  They  should  be  cut 
longer  than  appears  necessary  ;  they  can  easily  be 
cut  down  later  to  the  desired  dimensions.  In  width 
they  should  not  exceed  half  the  circumference  of  the 
limb  ;  there  is  a  tendency  to  make  them  too  wide, 
covering  part  of  the  anterior  surface  of  the  leg  or  fore- 
arm, and  causing  a  certain  amount  of  difficulty  in 
their  removal.  Adaptation  to  the  flexures  of  the 
limb  is  ensured  by  cutting  notches  that  allow  one  part  to 
ride  over  the  other  when  the  strip  is  bent. 

The  liquid  plaster  for  the  splint  should  be  made  in  a 
large  basin  with  cold  water,  without  salt.  According 
to  the  classical  formula,  more  plaster  than  water 
should  be  added,  five  parts  of  plaster  to  four  of  water. 
There  is  an  advantage,  however,  in  thickening  the 
paste  a  little  further,  by  the  addition  of  more  plaster 
than  is  prescribed,  and,  like  Calot,  I  use  for  choice  five 
parts  of  plaster  to  three  of  water  (by  volume).  An 
excellent  but  slower  method  consists  in  sifting  the 
plaster  through  the  tarlatan,  which  is  stretched  over  a 
basin,  until  the  powder  floats  on  the  surface  of  the 
paste  like  small  pieces  of  ice  in  water. 

When  the  paste  is  ready  it  should  be  used  at  once 
without  further  dilution  or  thickening.  It  is  better 
to  start  afresh  than  to  attempt  any  alteration  in  its 
consistency  :  any  attempt  at  improving  it  almost 
always  makes  a  failure  of  the  appliance. 

Whatever  the  type  of  appliance  used,  it  should  not 
cover  the  wound ;  gaps  are  cut  in  the  splints,  or  open- 
ings are  made.  To  recognise  the  position  of  wounds 
and  to  know  where  to  cut  out  an  opening,  it  is  enough 
to  mark  the  place  on  the  dressing  by  placing  a  few 
drops  of  tincture  of  iodine  on  the  gauze  immediately 


37^  TREATMENT   OF   FRACTURES 

previous  to  applying  the  plaster  ;  a  violet  stain  on  the 
appliance  will  soon  mark  the  position  of  the  wound 
to  be  uncovered. 

These  windows  are  made  with  a  bistoury  or  a  shoe- 
maker's knife  about  half  an  hour  after  the  plaster 
has  set ;  they  should  expose  the  skin  widely  round 
the  wound,  and  their  edges  should  be  covered  with 
gauze  or  bound  with  strapping. 

If  the  wound  or  wounds  are  very  extensive,  and  if. 
the  fracture  is  suppurating  profusely,  recourse  may 
be  had  to  interrupted  splints.     I  shall  discuss  their 
use  later  (see  p.  377 ),  but  confine  myself  for  the  present 
to  describing  their  construction. 

The  principle  is  to  apply  two  close-fitting  circular 
plaster  bandages,  one  above  and  one  below  the  region 
of  the  fracture,  and  to  unite  them  by  metallic  loops, 
or  by  plaster  loops  reinforced  by  wood,  wire,  or  tow, 
the  ends  of  which  are  incorporated  with  the  plaster. 
In  constructing  them,  the  fundamental  principles  of 
fixation  have  often  been  misunderstood — thus  metallic 
loops  passing  from  the  shoulder  to  the  forearm  have 
been  recommended  for  fractures  of  the  humerus. 
These  gross  therapeutic  errors  are  no  longer  made  at 
the  present  time,  and  the  interrupted  appliances  now 
made  rigidly  fix  the  two  bony  segments  to  be  im- 
mobilised. 

The  circular  plaster  bandage  should  extend  suffi- 
ciently far  along  the  limb  in  each  direction  to 
render  the  joints  above  and  below  the  fracture 
immobile. 

Briefly,  interrupted  appliances  which  originally  left 
too  much  of  the  limb  exposed  tend  at  the  present 
time  to  be  nothing  more  than  circular  appliances  with 
bracketed  interruptions.  This  development  was  in- 
evitable ;  the  laws  of  fixation  demanded  it. 

The  circular  plaster  bandages  are  applied  according 
to  the  usual  rules,  and  two  or  three  metal  loops,  pre- 
pared  beforehand   of   the   required    dimensions    and 


GENERAL  PRINCIPLED  IN  TREATMENT  :^>75 


J 


bent  in  the  right  place,  are  fixed  on  each  of  them  with 
a  plaster  bandage. 

The  bandage  may  be  carried  from  one  circular  part 
of  the  splint  to  the  other  by  covering  the  metallic 
loop  with  it,  or,  on  the  other  hand,  the  metal  may  be 
left  exposed. 

The  same  thing  may  be  done'with  any  more  or  less 
rigid  kind  of  support,  or  more  simply  still,  plaster 
strips  may  be  constructed 
from  a  fairly  long  piece  of 
bandage.  For  this  purpose 
it  is  enough  to  unite  the 
two  circular  portions  by  a 
few  longitudinal  strips  of 
plastered  bandage,  fairly 
long  and  not  too  tightly 
stretched,  round  the  ends 
of  which  a  few  turns  are 
made  with  another  bandage 
to  cover  and  secure  them  ; 
a  series  of  soft  connecting 
loops  is  thus  obtained, 
which  may  be  pulled  out- 
wards from  the  limb  by  the 
fingers  and  kept  in  that 
position  until  the  plaster 
dries. 

These  appliances  are  interesting,  but  as  a  matter 
of  fact,  however  well  made  they  may  be,  they  possess 
great  disadvantages  :  very  soon  the  limb  becomes 
loose  within  the  casing  enclosing  it ;  it  begins  to  have 
too  free  play,  and  fixation  is  less  rigorous  ;  over- 
riding occurs,  and  some  degree  of  angulation  between 
the  two  ends  of  the  shaft  is  produced,  so  that  the 
actual  therapeutic  and  orthopaedic  result  obtained  is 
mediocre. 

Hence  the  idea  of  piaster  casings  with  extensible 
metallic  brackets,  or  brackets  consisting  of  tubes  sliding 


Fig.  36.— Metal  loops  with 
(a)  a  spring,  (b)  nuts. 


376  TREATMENT   OF   FRACTURES 

one  within  the  other,  i.e.  continuous  extension  plaster 
appliances.  These  are  actually  only  copies  of  Pierre 
Delbet's  appliances.  But  these  modifications  are  con- 
venient, and  their  use  should  become  general. 

To  construct  them  it  is  enough  to  replace  the 
ordinary  flat  metal  loops  by  metal  slats  sliding  one 
over  the  other  which  can  be  fixed  by  means  of  a  wing 
nut,  or  by  hollow  rods  of  different  diameters  sliding 
one  within  the  other,  or  again  by  shafts  with  a  spring 
resembling  those  of  Delbet's  apparatus.  By  exerting 
traction  on  the  end  of  the  limb,  it  is 
possible,  if  necessary,  to  produce  the  ex-  /^ 

tension   judged   to    be   useful.     Perfora-         |^» 
tions  and  a  pin   allow  the  tubes  to  be      yiSi 


Fig.   37. — Piaster  appliance  with  continuous  extension  '  ■     V   'I 

by  springs  on  the  model  of  Delbet's  extension  shafts.  '     ' 

fixed  in  any  position.  Excellent  and  compact  ap- 
pliances are  constructed  in  this  way  for  the  leg  (see 
fig.  37)  ;  they  are  easily  improvised  everywhere  and 
ai'e  of  great  service. 

These  continuous  extension  plasters  are  far  prefer- 
able to  simple  plaster  appliances,  which  usually  reduce 
displacements  and  deviations  unsatisfactorily. 

Advantages  and  disadvantages  of,  and  indications 
for,  Plaster  appliances. — The  great  advantage  of  the 
plaster  appliance  is  that  it  is  easily  made,  and  reduces 
pain  by  producing  admirable  fixation,  diminishes  in- 
fection, and  makes  for  recovery. 

It  is  criticised  on  account  of  the  trouble  in  dressing 


GENERAL  PRINCIPLES  IN  TREATMENT    377 

and  supervising  these  wounds  which  it  causes,  and  its 
frequent  tendency  to  produce  compression  and  ulcera- 
tion. 

All  this  is  true,  but  it  is  all  a  matter  of  supervision, 
and  no  fracture  appliance  exists  which  does  not  demand 
a  great  deal  of  attention. 

Plaster  should  be  employed  whenever  rigorous 
fixation  is  required  for  a  patient  who  is  to  be  left  a 
comparative  degree  of  liberty  ;  for  this  reason  plaster 
is  the  ideal  transport  appliance  ;  lack  of  time  some- 
times prevents  its  use,  but  it  should  never  be  forgotten 
that  for  evacuation  nothing  can  take  its  place.  The 
best  plaster  for  this  purpose  is  the  classical  plaster  trough 
well  adjusted ;  a  postero-external  scapulo-metacarpal 
splint  for  the  arm  ;  a  dorsal  humero-metacarpal  splint 
for  the  forearm;  a  dorsal  pelvi-pedal  splint  for  the 
thigh ;  and  a  posterior  cruro-pedal  trough  for  the  leg. 

On  the  other  hand,  the  plaster  trough  does  not 
allow  of  continuous  extension,  and  it  is  for  this  reason, 
in  a  general  way,  that  it  is  not  advisable  except  at  the 
beginning  and  the  end  of  the  treatment. 

Circular  plaster  appliances  are  scarcely  suitable 
except  in  the  third  stage,  when  reduction  by  extension 
has  already  been  produced,  and  union  is  on  the  point 
of  commencement  or  completion. 

On  the  other  hand,  continuous  extension  plasters 
are  excellent  appliances  for  the  active  period  of  treat- 
ment, if  it  may  so  be  termed. 

Interrupted  appliances  are  not  often  advisable  : 
there  has  been  much  misuse  of  these  appliances  which 
so  many  surgeons  suppose  they  have  invented,  whereas 
they  had  been  abandoned  for  thirty  years,  and  have 
been  recently  reintroduced  by  Gourdet.  The  very 
great  ingenuity  required  and  displayed  in  their  con- 
struction has  been  one  of  the  factors  of  their  success. 
They  are  now  being  given  up,  which  is  only  right ;  as 
a  means  of  fixation  they  have  given  indifferent  results, 
and  they  have  often  sewed  to  conceal  serious  errors 


378  TREATMENT    OF    FRACTURES 

in  treatment.  They  immobilise  badly,  and  soon  allow 
insidious  slippings  and  secondary  over-riding,  and 
should  therefore  be  used  only  for  short  periods  in 
particular  cases,  and  in  definite  circumstances — when, 
for  instance,  an  extensive  wound  requires  to  be  widely 
exposed,  in  a  patient  who  is  able  to  get  about. 

In  fact,  if  the  fracture  suppurates,  it  is  not  an 
interrupted  plaster  appliance  that  is  required,  but  an 
operation  ;  if  the  wound  is  large  and  the  patient  con- 
demned to  bed  for  any  reason,  he  will  do  far  better 
with  a  suspension  apparatus  ;  if  the  wound  is  not 
suppurating  and  the  progress  of  the  case  is  normal,  in- 
frequent dressings  allow  of  a  plaster  trough  being  used. 

The  practice  of  immediate  or  secondary  sub-periosteal 
esquillectomy,  the  aseptic  development  of  the  wounds, 
and  the  rapid  formation  of  a  periosteal  callus,  allow 
the  necessity  for  appliances  specially  designed  to 
facilitate  daily  dressings  to  be  regarded  as  unusual  : 
the  treatment  of  gunshot  fractures  thus  tends  closely 
to  approximate  to  that  of  fractures  in  time  of  peace. 

2.  Limited  immobilisation  of  the  fractured 
AREA. — The  real  solution  of  this  difficult  problem  is 
entirely  due  to  Pierre  Delbet,  who  set  out  to  find  a 
means  of  maintaining  reduction  without  interfering 
with  the  movements  of  the  limb.  With  this  object, 
and  to  immobilise  fractures  without  fixing  the  adjacent 
joints,  he  invented  a  series  of  excellent  appliances  which 
may  be  described  as  being  an  extensible  external  pros- 
thesis, buttressed  against  the  epiphyseal  projections 
of  the  fractured  bone,  or  other  bony  projections  immedi- 
ately adjacent  to  and  intimately  connected  with  it. 

There  are  four  types  :  in  the  arm,  the  appliance 
takes  purchase  above  from  a  metal  crutch  in  the 
axilla,  and  below  from  a  curved  plate  on  the  flexed 
forearm ;  in  the  forearm,  below  from  the  lower  end  of 
the  ulna  and  the  radius,  the  trapezium  and  the  unci- 
form bone,  above  from  a  plaster  surrounding  the 
flexed  elbow  ;    in  the  thigh,  the  points  of  support  above 


GENERAL  PRINCIPLES  IN  TREATMENT    37^ 

are  the  ischium  and  great  trochanter,  below  a  plaster 
collar  around  the  supra-condylar  depressions;  in  the 
leg,  above  from  the  depression  beneath  the  head  of  the 
tibia,  below  from  the  malleolar  prominences. 

The  leg  appliance  is  a  continuous  extension  plaster  ; 
the  other  appliances  are  special  instruments  ;  those 
for  the  arm  and  forearm  may  be  improvised  by  simple 
means  ;  the  thigh  apparatus  cannot  be  improvised ; 
it  is  also  difficult  to  apply,  and  painful  if  not  very  well 
applied. 

These  remarkable  instruments  will  be  discussed  in 
connection  with  each  individual  fracture. 

3.  Fixation  by  suspension  with  continuous  ex- 
tension.— This  excellent  method  is  being  more  and 
more  widely  applied,  a  state  of  things  for  which  Blake 
is  largely  responsible.  At  first  it  appears  complicated ; 
it  is  actually  very  simple,  but  requires  a  good  deal  of 
supervision  and  careful  attention  to  details. 

Though  applicable  in  all  regions  and  easily  im- 
provised, it  has  the  disadvantage  of  confining  the 
patient  to  bed ;  for  this  reason  its  use  in  the  upper 
limb  has  been  restricted.  It  appears  the  most  suitable 
method  for  the  thigh,  and  also  for  the  leg  in  certain 
fractures. 

The  principle  consists  in  placing  the  limb  in  a  ham- 
mock suspended  from  a  frame  by  cords  passing  over 
a  pulley  carried  on  the  frame,  and  kept  in  equilibrium 
by  weights,  while  a  continuous  pull  is  applied  in  a 
suitable  direction. 

The  sling  for  the  upper  limb  is  represented  by  two 
large  diamond-shaped  slings  of  soft  material,  28  to 
32  inches  long  and  4  inches  wide,  passing  "round  the 
arm,  one  above  and  one  below  the  fracture.  The  two 
extremities  of  each  sling  have  slits  through  which  the 
suspension  cord  passes.  The  latter  passes  over  a 
pulley  situated  on  the  frame  (which  will  be  described 
later)  in  a  line  perpendicular  to  the  fragments  of  the 
bone.     The   cord  passes   over   a   second  pulley,  and 


380 


TREATMENT   OF   FRACTURES 


supports ,  a  weight  exactly  counterbalancing  that  of 
the  arm.  The  two  fragments  are  thus  fixed  in 
suspension  ;  their  relative  position  is  maintained  in 
space  without  injury  or  friction. 

In  the  forearm,  thigh,  and  leg,  the  sling  is  repre- 
sented by  a  series  of  narrow  strips  of  material,  stretched 
on  a  metal  frame  consisting  of  strip  iron  "4  inch  wide 
and  J  inch  thick.  The  suspending  slings  for  the  limb 
are  6  inches  wide  and  20  inches  long  ;  they  are  passed 
over  the  metal  frame  on  each  side  and  fixed  with 
safety-pins.     This  arrangement  allows  easy  inspection 

of  posterior  wounds  ; 
it  is  sufficient,  in  fact, 
to  detach  one  strip  by 
removing   the  pin   to 
have  access  to  the  part 
of  the  limb  which  it 
is  desired  to  examine. 
If     the     wound    is 
oozing  at  all,  the  strip 
in   contact    with    the 
dressing   may    be    re- 
placed  by   rubber  or 
by      an      aluminium 
plate  moulded  on  the 
limb  and  supported  by  bending  it  over  the  edges  of 
the  metal  frame  :    cleanliness  is   much  facilitated  in 
this  way. 

The  four  corners  of  the  frame  are  fitted  with  small 
figure-of-eight  hooks,  to  which  the  suspension  cords 
are  attached.  The  two  upper  cords  unite  20  inches 
above  the  frame,  the  single  cord  thus  formed  passing 
over  a  pulley  placed  on  the  upper  frame  in  a  line 
vertically  over  the  ends  of  the  sling,  or  at  a  point 
slightly  beyond  it.  Beyond  this  the  cord  descends, 
supports  a  sliding  central  pulley  from  which  a  weight 
is  suspended,  and  unites  with  the  cord  from  the  lower 
end  of  the  sling,  which  is  formed  in  the  same  way  and 


Fig.  38. — Suspension  apparatus 
(see  figs,  105  and  115). 


GENERAL  PRINCIPLES  IN  TREATMENT     381 

passed  over  a  pulley  vertically  above  the  lower  end  of 
the  splint.  The  centre  weight  should  exactly  counter- 
poise the  limb  and  keep  it  in  suspension  (see  fig.  115). 

I  shall  explain  the  exact  arrangement  in  connection 
with  each  limb-segment  :  the  above  diagram  (fig.  38) 
is  sufficiently  explicit  for  the  present. 

The  superstructure  is  more  or  less  complex  according 
to  what  it  is  desired  to  do.  In  the  most  complete 
model  it  consists  of  a  double  frame,  the  vertical  pillars 
of  which,  about  6^  feet  in  length,  are  prolongations 
of  the  bed-posts,  and  whose  upper  horizontal  traverses 
are  slightly  longer  than  the  bed.  These  pillars  may 
be  made  of  metal  or  of  white  wood.  The  transverse 
bars  are  notched  or  pierced  at  regular  intervals  :  these 
holes  or  notches  are  intended  to  fix  or  receive  longi- 
tudinal bars,  movable  at  will,  which  are  placed  in  line 
with  the  bed  or  with  the  limb  ;  they  are  themselves 
pierced  by  a  series  of  holes  at  regular  intervals,  upon 
which  pulleys  may  be  hung.  The  latter  are  of  the 
ordinary  commercial  type. 

In  other  words,  four  vertical  pillars  support  a  hori- 
zontal frame,  along  which  suspension  pulleys  may  be 
attached  in  any  direction  desired.  A  perfectly  balanced 
suspension  is  therefore  obtained,  which  permits  move- 
ment of  all  kinds. 

In  the  most  simple  model,  which  is  quite  satisfac- 
tory in  practice,  although  rather  less  convenient,  two 
vertical  supports,  6|  feet  in  length,  support  a 
horizontal  bar  which  is  placed  in  the  line  of  traction 
desired,  and  from  which  the  necessary  pulleys  are  sus- 
pended. One  at  each  end  is  sufficient ;  over  these, 
as  has  been  said,  pass  suspension  cords,  which  meet 
beneath  a  free  central  pulley  supporting  a  weight. 

The  weight,  which  should  be  4  to  8  kilograms  for 
the  lower  limb,  is  provided  by  a  series  of  sheets  of 
lead  or  a  bag  of  sand. 

Extension  is  carried  out  on  the  ordinary  principles, 
by  means  of  adhesive  strapping.     Or  again,  the  pull 


3^2         TREATMENT   OF   FRACTURES 

may  be  exerted  simply  by  means  of  a  stirrup  of  soft 
material,  which  is  applied  methodically  to  the  limb  by- 
a  bandage.  With  some  practice,  perfect  continuous 
extension  may  be  produced  in  this  way. 

These  appliances  possess  great  advantages  :  they 
allow  very  easy  supervision  of  the  wound,  the  fracture, 
and  of  the  whole  limb  ;  they  greatly  facilitate  the 
dressing  of  the  wound  ;  they  rapidly  ease  the  patient, 
who  is  no  longer  in  pain  and  is  able  to  move  in  all 
directions,  even  to  raise  himself,  and  to  move  the 
limb  very  easily  and  without  pain  ;  finally,  the  sus- 
pension of  the  limb  above  the  level  of  the  bed  makes 
nursing  an  easy  matter,  and  makes  for  the  physical 
hygiene  of  the  patient.  A  further  advantage  is  that 
they  permit  small  movements  of  muscles  and  joints, 
and  therefore  favour  recovery  of  function. 

C.  Choice  of  a  fixation  appliance. — It  must  not  be 
supposed  that  there  is  a  universal  method  of  fixa- 
tion, and  one  appliance  which  is  better  than  all  the 
rest  for  each  type  of  fracture.  Of  the  different  types 
studied  above,  there  is  not  one  which  is  not  indicated 
by  particular  conditions  :  to  speak  very  roughly,  the 
trough  should  be  regarded  as  the  temporary  emergency 
appliance  ;  plaster  as  the  appliance  for  transport  and 
convalescence ;  while  Delbet's  apparatus  and  its  modi- 
fications, the  suspension  appliances,  as  those  to  be 
used  for  treatment. 

D.  Duration  of  fixation. — This  should  be  regu- 
lated according  to  the  fracture  and  the  patient.  In 
general,  fixation  is  rarely  too  prolonged.  Fixation,  it 
is  true,  is  severely  criticised ;  it  is  made  responsible 
for  stiffened  joints,  muscular  atrophy,  and  trophic 
disorders  of  the  skin.  But  it  is  far  from  being  proved 
actually  to  cause  these,  and  its  disadvantages  are 
enormously  exaggerated.  When  all  is  said  and  done, 
the  advantage,  from  a  local  point  of  view,  in  allowing 
a  case  of  fracture  to  walk  too  early  is  certainly  not 
very  great.     The  violence  of  the  original  injury,  per- 


GENERAL  PRINCIPLES  IN  TREATMENT    '.m 

sistent  infection,  and  faulty  reduction  are  the  real 
causes  of  permanent  loss  of  functio^i ;  fixation  pro- 
longed for  two  or  three  months  leJ-ds  to  no  serious 
persistent  trouble  if  the  wounds  a^e  not  septic.  Im- 
mobilise a  case  of  gonorrhoeal  arth  itis  for  three  months 
or  a  tuberculous  joint  for  eighteen,  and  when  the 
patient  has  recovered,  the  neighbouring  joints  will 
rapidly  redevelop  free  play.  Jf  it  is  otherwise  after 
a  fracture,  there  is  a  Iocj*  cause — ^distant  osseous 
contusion,  the  formation  of^ssures,  etc.  In  any  case, 
the  therapeutic  method  i^  not  responsible. 

After  sub-periosteal  pquillectomy,  even  when  the 
callus  appears,  both  clr^^^Hy  and  hy  X-rays,  to  have 
formed  (after  forty  to^fty  days  for  the  upper  limb, 
sixty  to  eighty  days-or  the  lower),  fixation  should  he 
prolonged  for  a  furP^^  twenty  days  at  least,  since  the 
callus  is  not  alwa^  '^^^V  fi^^^  and  may  become  bent 
secondarily.  It  i.'^*  this  time  that  walking  appliances 
should  be  used. 

It  should  bfConsidered  a  definite  rule  that  sixty 
days'  fixatioris  necessary  for  the  upper  limb,  and 
eighty  to  a  l-^^dred  at  least  for  the  lower. 

E.  Delayf  consolidation. — If  consolidation  has  not 
occurred  ?  ^^^  ^^^  ^f  this  period,  there  is  reason  for 
adopting^^^cu^ial  treatment  (local  dressings  with 
calomel  ^ntment),  and  for  giving  a  little  iodide.  This 
often  T^duces  the  desired  result  in  a  few  days. 

jf  .ere  is  no  result,  the  surfaces  of  the  fracture  may 
be  r^P^d  with  a  curette.  I  have  once  seen  a  callus 
for  ^®^y  rapidly  after  this  instrumental  irritation. 

.astly,   if  everything  has  failed,   I  advise  the  im- 

adiate  introduction  of  a  metal  suture,  without  wait- 

ng  until  the  end  of  the  period  which  is  stated  to 

elapse   before   pseudarthrosis  *   can   be   said   to   have 

*  Very  recently  in  a  fracture  of  the  humerus  after  secondary 
esquillectomy  which  did  not  consohdate,  I  introduced  a  metal  suture 
on  the  nmety-second  day  :  at  th^  first  dressing,  ten  days  after- 
wards, the  callus  had  formed 


384 


TREATMENT   OF    FRACTURES 


occurred,  and  particularly  without  waiting,  as  is  the 
usual  practice,  Uv  the  wound  to  heal  completely. 

F.  Treatment  su»seauent  to  immobilisation. — Massage, 
hot  water,  hot  aii  passive  and  active  movements, 
should  be  introduced  as  early  as  possible.  On  the 
other  hand,  mechamtherapy  is  usually  dangerous, 
and  should  not  form  ]^art  of  the  later  treatment  of 
fractures. 


CHAPTER    XII 

FRACTURES   OF  THE  HUMERUS 

From  the  point  of  view  of  treatment,  there  are  four 
types  of  fracture  of  the  shaft  of  the  humerus  : 

Fracture  of  the  neck  of  the  humerus  ; 

Sub-deltoid  fracture  ; 

Fracture  of  the  middle  of  the  shaft ; 

Supra-condylar  fracture  of  the  elbow. 

These  are  obviously  rather  rough  distinctions  ;  there 
are  many  types  that  are  intermediate  between  these, 
but  typical  cases  are  still  the  more  numerous,  and  in 
each  of  the  groups  mentioned  there  are  characteristic 
peculiarities,  which  demand  a  special  method  of  apply- 
ing the  general  rules  for  treatment  outlined  in  the 
previous  chapter. 

I.  Fracture  of  the  Neck  of  the  Humerus  (Sub-epiphyseal 

Fracture) 

1.  Anatomical  Features. — In  the  most  typical 
cases,  the  direction  of  the  fracture  is  transverse.  It  is 
clearly  extra-articular  at  the  level  of  the  neck  of  the 
bone  or  immediately  below  it.  The  upper  fragment, 
including  the  head  and  the  tuberosities,  is  often  pro- 
longed down  the  front  and  outer  side  of  the  bone  by  a 
splinter  of  some  length  formed  from  the  external  face 
of  the  shaft  at  some  distance  troiii  the  biceps  tendon, 
which  remains  intact  on  its  inner  side,  or  is  torn  away 
by  the  violence  of  the  injury. 

Fissures  are  very  often  found  in  the  lower  fragment, 

385 


:,sG  TREATMENT    OF    FRACTURES 

and  there  is  almost  invariably  severe  injury  to  the 
cancellous  tissue  of  the  head  of  the  bone.  The  carti- 
lage is  sometimes  cracked,  or  even  split  clean  across. 

A  greater  degree  of  injury  is  the  crushing  of  the 
epiphysis  and  shaft,  dealt  with  in  P;irt  I  (p.  lO-'O- 

There  are  no  large  or  adherent  splinters  ;  on  the 
other  hand,  large  numbers  of  small  bony  fragments 
are  found,  with  a  quantity  of  bone  dust,  which  the 
injury  scatters  amongst  the  muscles  over  the  promin- 
(^nce  of  the  shoulder. 

When  the  missile  enters  or  passes  out  through 
the  posterior  region  of  the  shoulder,  at  the  level  of 
the  axilla,  the  circumflex  nerve  may  be  involved  ;  the 
radial  (musculo-spiral)  is  more  often  injured  as  it 
passes  out  of  the  axilla  :  the  two  ends  of  the  nerve 
retract  in  opposite  directions,  and  subsequent  repair 
is  always  difficult  and  may  be  impossible. 

2.  Physiological  Features. — Displacement  of  the 
upper  fragment  is  caused  by  the  muscles  connecting 
the  scapula  with  the  tuberosity  (supraspinatus,  infra- 
spinatus, and  teres  minor).  As  a  result  of  their  action, 
whioh  is  more  powerful  than  that  of  other  muscles 
inserted  into  the  tuberosities,  the  upper  fragment  is 
abducted  and  externally  rotated,  that  is  to  say,  the 
bead  of  the  humerus  gets  out  of  contact  with  the 
glenoid  cavity,  and,  with  its  cartilaginous  surface 
downwards,  rotates  in  the  joint  cavity,  which  is  en- 
larged by  expansion,  and  often  lacerated  at  some  point. 

If  the  upper  fragment  includes  the  external  splinter 
from  the  shaft  to  which  I  have  referred  above,  this 
points  backwards,  and,  entering  the  deltoid,  threatens 
to  pierce  the  skin. 

On  the  other  hand,  the  lower  fragment,  adducted 
by  the  latissimus  dorsi,  corar  )-brachialis,  and  pec- 
is)ralis  major,  and  pulled  upwards  by  the  deltoid, 
assumes  a  position  deep  to  the  coracoid  process.  There 
!s.  in  fact,  very  wide  separation  and  displacement  of 
the  fragments. 


FRACTURES   OF    THE   HUMERUS     ;'>87 

3.  Clinical  Course. — There  can  be  no  question  of 
the  case  running  a  course  that  does  not  require  any 
surgical  intervention  :  without  operation  infection  is 
'  prone  to  cause  the  development  of  gas  gangrene  (since 
there  are  severe  muscular  lesions),  osteomyelitis,  or 
arthritis.  Arthritis  is  almost  unavoidable,  in  the 
first  place  because  the  infected  bony  region  is  in  im- 
mediate contact  with  the  joint,  also  because  there  are 
often  fissures  in  the  head  of  the  bone  which  carry 
infection  nearer  and  nearer  to  the  joint  cavity,  and 
lastly  because  osteomyelitis  of  the  upper  fragment 
passes  gradually  upwards,  and  infection  of  the  joint 
occurs  after  a  few  days  through  the  ulcerated  carti- 
lage. I  possess  a  specimen  showing  this  last  method 
of  spread  very  clearly. 

It  is  therefore  always  necessary  in  practice  to  inter- 
vene in  order  to  prevent  rapidly  fatal  complications. 

What  becomes  of  the  fracture  after  an  early  opera- 
tion ? 

Let  us  suppose  a  minimum  degree  of  intervention, 
a  falsely  conservative  operation  {i.e.  an  attempt,  which 
is  ultimately  unsuccessful,  to  preserve  as  much  of  the 
injured  structures  as  possible)  which  is  limited  to  the 
removal  of  the  missiles,  cleaning  the  approaches  to 
the  actual  region  of  the  fracture  through  the  wound 
of  entry  or  exit,  removal  of  free  splinters  which  the 
forceps  happen  to  encounter,  in  a  wound  accessible 
with  difficulty,  because  nothing  further  appears  at  the 
moment  to  be  necessary.  Let  us  suppose  even  a  rather 
more  comprehensive  operation,  which  deals  with  the 
bony  area,  cuts  off  the  sharp  point  of  the  upper  frag- 
ment, and  passes  a  drainage  tube  through  the  region  ; 
the  prevention  of  serious  and  rapidly  fatal  sepsis  is 
realised  in  this  way,  but  chronic  osteomyelitis  will  be 
unavoidable,  the  wound  will  suppurate  profusely,  and 
the  joint  will  probably  be  invaded,  owing  to  its  con- 
tiguity. 

This  persistent  septic  condition  will  render  it  very 


388 


TREATMENT   OF   FRACTUBE8 


difficult,  if  not  impossible,  to  achieve  even  an  ap- 
proximate reduction  which  will  necessitate  the  ex- 
tremely inconvenient  fixation  of  the  lower  fragment  in 
line  with  the  upper,  that  is  to  say,  elevation  of  the  arm 

above  the  horizontal  in 
a  position  of  abduction 
and  external  rotation. 
It  may  therefore  be 
supposed  a  priori  that 
the  reduction  will  be 
bad,  and,  as  prolonged 
suppuration  in  a  sub- 
epiphyseal  region, 
where  the  periosteum  is 
weak  and  thin,  is  always 
likely  to  cause  pseud - 
arthrosis,  and  also 
since  there  is  often  some 
muscular  interposition, 
there  will  be  every 
reason  to  expect  a  de- 
plorable result. 

In  fact  numbers  of 
cases,  treated  by  in- 
adequate methods, 
which  escape  the  serious 
consequences  of  sup- 
purative -  arthritis  and 
juxta- articular  osteo- 
myelitis, are  in  a 
lamentable  condition  at 
the  end  of  six  or  eight 
months  ;  the  head  of  the 
humerus,  separated 
from  its  vascular  connection  with  the  shaft,  becomes 
rarefied  and  almost  translucent  under  X-rays ;  foetid 
pus  escapes  through  two  or  three  sinuses,  bulky  peri- 
articular callus  produces  a  kind  of  circular  ankylosis, 


Fig.  39. — Radiograph  of  a  sub- 
epiphyseal  fracture  of  the  head  of 
the  humerus,  six  months  after  the 
wound  was  received ;  treatment 
was  limited  to  cleaning  the  soft 
parts  and  passing  a  drainage  tube 
through  the  fractured  area.  Foetid 
suppuration  persisted,  with  very 
bad  general  condition,  albuminuria, 
etc.  I  removed  the  head  of  the 
bone  by  the  classical  method  ;  it 
was  completely  free  and  necrosed, 
with  the  cartilaginous  face  down- 
wards, in  an  enlarged  articular 
cavity  full  of  pus.     (See  fig.  44.) 


FRACTURES   OF    THE   HUMERUS     389 

isolating  the  head  of  the  bone,  without  producing 
satisfactory  bony  union  between  the  epiphysis  and  the 
shaft. 

To  cure  these  unhealthy,  wasted,  sallow  patients,  a 
late  secondary  resection  is  required,  the  functional  gain 
of  which  is  necessarily  very  poor,  since  the  muscles 
havf"  become  adherent  and  all  the  tissues  round  the 
joint  are  sclerosed  and  rigid.  Totally  different  action 
must  therefore  be  taken. 

4.  Indications  for  early  Treatment. — Fracture 
of  the  neck  of  the  humerus  should  be  treated  early  by  typical 
sub-periosteal  articular  resection.  As  soon  as  the 
diagnosis  is  confirmed  by  X-rays  or  by  an  exploratory 
incision  of  the  exit  wound,  th6  classical  resection  should 
be  carried  out. 

The  joint  is  exposed  by  a  rather  low  antero-internal 
inter-deltoid  incision  ;  the  capsule  being  opened  with 
a  bistoury,  the  rest  of  the  operation  is  performed  with 
the  cutting  rugine  (see  Part  I,  p.  23). 

Generally  the  intra-articular  damage  which  will  be 
found,  and  which  the  radiograph  did  not  indicate,  will 
cause  surprise  :  the  Assuring  of  the  cartilage  men- 
tioned above  will  almost  always  be  seen  ;  often  one 
or  two  small  osteo-cartilaginous  fragments  will  even 
be  found  free  in  the  joint  cavity. 

The  head  of  the  bone  is  gripped  by  strong  forceps 
and  pulled  outwards,  while  the  sharp  rugine  carefully 
separates  the  periosteum  and  the  capsule  round  the 
anatomical  neck  near  the  tuberosities  and  along  the 
shaft  splinter,  if  one  exists. 

There  will  be  often  some  difficulty  in  gripping  the 
head  of  the  bone,  which  is  no  longer  in  contact  with 
the  glenoid  fossa,  but  lower  down  and  within  an 
enlarged  synovial  cavity. 

The  lower  fragment  is  thoroughly  exposed  and  ex- 
amined, and  gently  cleaned  with  the  curette,  or  if 
necessary,  trimmed  with  bone-cutting  forceps. 

The  operation  is  concluded  by  careful  cleaning  of 


390  TREATMENT   OF   FRACTURES 

the  soft  parts,  excision  of  all  loose  muscular  debris, 
and  removal  of  any  small  splinters  buried  in  the 
muscles. 

The  wound  is  left  open ;    a  drainage  tube  placed 
in  the  glenoid  cavity  passes  out  through  a  posterior 
counter-incision  at  the  seat  of  election  {see  Part  I 
p.  120  .     The  anterior  incision  and  the  wounds  of  entry 
and  exit  are  loosely  plugged  with  gauze. 

Fixation  is  ensured  by  a  bandage  binding  the  arm 
against  the  body  ;  the  case  is  then  conducted  like  one 
of  resection  for  articular  fracture. 

Advantages  of  this  method. — ^No  doubt  this  procedure 
will  appear  drastic  :  at  the  front,  some  surgeons  will 
say  that  in  the  early  stage  it  appears  too  drastic,  since 
a  restricted  operation,  ostensibly  more  conservative, 
is  sufficient  to  prevent  serious  developments  due  to 
infection,  to  obviate  disarticulation,  or  to  prevent 
death  ;  at  the  base,  others  will  recall  rare  cases  in 
which  cure  was  effected  with  little  trouble. 

Neither,  however,  should  forget  that  among  the 
cases  of  this  sort  that  they  have  seen  there  have 
been  rapid  deaths  from  gas  gangrene,  osteomyelitis, 
and  acute  arthritis,  that  an  emergency  operation  for 
resection  of  the  joint  has  sometimes  become  necessary 
on  the  third  or  fourth  day,  when  the  operation  on  the 
fracture  had  been  performed  only  twenty-four  or 
forty-eight  hours  previously ;  lastly,  that  numbers  of 
cases  evacuated  still  persistently  suppurate,  eventually 
requiring  an  extensive  operation  after  months  of  suffer- 
ing and  repeated  drainage. 

In  fact,  the  record  of  incomplete  qperations  is  frankly 
a  bad  one ;  these  are  the  operations  claimed  to  be 
conservative  on  the  strength  of  a  few  fortunate  cases 
which  are  rendered  more  prominent  since  the  failures 
(deaths,  disarticulations,  etc.)  are  no  longer  there  to 
darken  the  prospect. 

Does  early  excision  give  better  results  ?     Decidedly. 

It  invariably  prevents  serious  septic  phenomena  ; 


FRACTURES   OF    THE    HUMERUS      -Sin 

after  it  there  are  neither  deaths  from  uncontrollable 
sepsis  nor  secondary  disarticulations  ;  under  careful 
treatment  all  cases  recover  in  a  short  time  (forty  days 
to  two  months).  This  is  the  first  important  reason, 
sufficient  to  prove  that  intervention  is  truly  conserva- 
tive. It  has  the  disadvantage  of  removing  too  large 
a  quantity  of  bone  for  function  to  be  as  well  preserved 
as  it  rtiay  be  after  excision  limited  to  the  epiphysis* 
But  this  does  not  mean  that  its  results  are  bad.  To 
appreciate  them,  conclusions  should  not  be  drawn 
from  the  very  mediocre  results  of  late  excision.  There 
is,  in  fact,  from  this  point  of  view,  a  vast  difference 
between  these  and  excisions  in  the  earliest  stages  ; 
the  latter,  correctly  performed,  preserve  the  innerva- 
tion of  a  healthy  deltoid  ;  asepsis  having  been  achieved, 
all  the  muscle  not  directly  involved  in  the  original 
injury  remains  intact,  and  does  not  undergo  perma- 
nent sclerosis  ;  this  muscle,  moreover,  actually  retains 
its  original  action,  since  its  origin  and  insertion  are 
preserved.  The  rapidity  of  the  cure  allows  massage 
and  electrotherapy  to  be  begun  early,  with  the  result 
that  at  the  end  of  three  or  four  months  regular  active 
exercise  is  possible.  Further,  if  the  operation  has  left 
the  capsule  and  periosteum  intact,  ligamento-periosteal 
continuity  is  obtained,  which  has  a  great  effect  on  the 
functional  conditions,  even  if  extensive  regeneration 
does  not  occur.  Owing  to  this,  cases  in  which  resec- 
tion has  been  performed  regain  a  very  satisfactory  use 
of  the  limb  ;  the  arm  is  certainly  not  rigidly  fixed,  but 
contraction  of  the  shoulder  muscles  allows  of  fixation 
of  the  humerus  ;  it  is  pulled  upwards  into  contact 
with  the  glenoid  cavity,  and  in  that  position  the 
elbow  can  be  abducted  and  the  arm  raised  more  or 


*  To  judge  the  functional  results  of  excision  of  the  shoulder,  it 
is  essential  to  distinguish  between  resections  limited  to  the  epiphysis 
or  joitrt,  and  those  involving  both  it  and  the  shaft.  This  distinction 
has  not  always  been  drawn  in  works  which  condemn  excision  in 
wounds  of  the  shoulder  as  gi\'ing  bad  results. 


392         TREATMENT    OF    FRACTURES 

less  towards  the  horizontal,  either  outwards  (action 
of  the  acromial  fasciculi  of  the  deltoid),  forwards 
(action  of  the  clavicular  fasciculi),  or  backwards 
(action  of  the  scapular  fasciculi).  Given  the  usual 
laceration  of  the  muscle  at  some  point,  these  three 
movements  are  not  realised,  so  to  speak,  in  perfection, 
since  the  combination  requires  an  absolutely  intact 
deltoid,  but  the  arm  is  really  active,  and  does  not 
merely  hang  against  the  body,  as  in  a  case  where  the 
deltoid  is  paralysed  by  the  original  injury  or  a  care- 
less incision  severing  the  circumflex  nerve,  or  has  been 
practically  destroyed  by  prolonged  suppuration. 

It  will  perhaps  be  said  that  this  optimistic  picture 
does  not  correspond  with  the  reality.  It  is  certainly 
a  picture  of  the  favourable  results  only  to  be  obtained 
by  the  correct  operation  on  a  vigorous  subject,  and  by 
well-directed  subsequent  treatment.  But  account 
must  be  taken  of  cases  of  weaker  physique,  in  which 
the  operation  and  subsequent  treatment  have  been 
technically  faulty  :  excision  of  the  head  of  the;  humerus 
performed  at  the  front  by  the  sub-capsulo-periosteal 
method  demands  careful  attention  from  the  surgeon 
in  charge  at  the  base  hospital,  and  not  the  incom- 
prehensible indifference,  a  justification  of  which  is 
attempted  by  speaking  later  of  the  bad  results  of  the 
excision.  Cases  in  which  I  have  carried  out  both  the 
operation  and  the  subsequent  treatment  until  cure 
was  complete  have  always  given  very  satisfactory 
results.  I  recently  looked  after  a  case  upon  which 
Gayet  and  Truchet  had  operated,  in  which  the  func- 
tioning of  the  arm  is  remarkable,  in  spite  of  the  loss  of 
3|  in.  of  the  bone.  All  the  movements  of  the  humerus 
can  be  performed  to  two-thirds  of  their  normal  extent. 

Further,  the  worst  results  may  often  be  bettered 
by  humero-scapular  ankylosis,  by  repair  of  the 
scapular  muscles,  or  by  an  artificial  appliance. 

This  discussion  may  be  summarised  in  the  following 
way  :    in  sub-epiphyseal  fractures,  a  solid  callus  with 


FRACTURES   OF    THE    HUMERUS      :yxi 

ankylosis  of  the  shoulder- joint  and  without  a  sinus 
is  better  than  the  result  given  by  an  extensive  resection, 
but  there  is  never  any  certainty  of  obtaining  this 
favourable  result ;  a  great  risk  is  run,  when  the  latter 
is  expected,  of  attaining  nothing,  and  resection  is  the 
only  absolute  guarantee  against  disaster.  For  this 
reason  resection  is  in  reality  the  truly  conservative 
treatment :  the  average  of  results  obtained  by  early 
resection  well  performed  is  very  satisfactory  ;  having 
regard  to  the  seriousness  of  the  lesions,  it  is  decidedly 
perferable  to  what  one  can  obtain  in  any  other  way, 
provided  always  that  the  operation  is  undertaken  early, 
and  that  it  leaves  the  musculature  intact ;  sometimes 
its  results  are  remarkable. 

5.  The  Treatment  of  cases  already  under 
Treatment  or  seen  at  a  late  stage. — Four  types 
mav  occur  : 

[a]  A  case  progresses  well  after  a  restricted  operation 
confined  to  the  fractured  region  and  its  immediate  sur- 
roundings. Every  effort  should  be  directed  towards 
securing  fixation  in  a  good  position.  After  X-ray 
examination,  a  plaster  appliance  is  fitted,  so  as  to  fix 
the  limb  in  a  suitable  position,  that  is  to  say,  bringing 
the  lower  fragment  in  line  with  the  upper.  A  plaster 
bandage  should  be  used,  and  an  opening  made  where 
the  wounds  are  situated.  If  one  of  these  is  large,  a 
bracketed  interruption  may  be  fitted,  but  the  ideal 
arrangement  for  wounds  which  suppurate  little  or  not 
at  all  is  a  plaster  bandage  round  the  upper  limb  and 
a  plaster  jacket,  which  ensures  the  best  possible  im- 
mobilisation. 

For  this  purpose,  the  trunk  is  covered  by  a  vest  or 
by  gauze  padding,  and  a  jacket  is  made  by  means  of 
plaster  bandages.  It  is  useless  to  incorporate  splints  ; 
two  or  three  bandages  5  yards  long  are  enough  to 
cover  the  chest  with  a  moderately  resistant  casing, 
moulded  over  the  shoulders  and  clavicles.  When  its 
thickness  is  considered  suitable,  a  few  figures-of-eight 


394 


TREATMENT   OF   FRACTURES 


are  carried  round  the  axilla,  the  strapping  being  passed 
from  the  shoulder  on  to  the  upper  limb,  and  then 
down  the  arm  and  forearm  as  far  as  the  metacarpus. 
The  arm  is  fixed  in  abduction,  the  elbow  being  at  some 
distance  from  the  trunk,  the  forearm  flexed  in  semi- 

pronation,  and 
the  thumb 
directed  up- 
wards. 

When  the 
upper  limb  is 
entirely  covered 
by  three  regu- 
larly w  o  u  n  d 
bandages,  and 
as  soon  as  the 
plaster  has 
dried,  openings 
are  cut  with  a 
bistoury  which 
will  suitably 
expose  the 
wounds.  There 
need  be  no 
h  e  s  i  t  a  tion  in 
making  an 
opening  suffi- 
ciently wide  for 
the  plaster  not 
to  be  soiled ; 
pads  are  slipped 
under  the  edges 
of  the  opening  to  prevent  their  disintegration,  and  an 
opening  is  cut  to  free  the  lower  borders  of  the  axilla. 
This  appliance  is  worn  for  about  a  month.  At  the 
end  of  this  period,  healing  will  generally  be  complete. 
The  union  of  the  bone  is  tested,  and  if  it  has  occurred, 
the  restoration  of  movement  is  begun. 


Fig.  40. — Plaster  with  a  window-opening. 


FRACTURES   OF    THE   HUMERUS     :v.)o 

If  the  wounds  are  more  extensive,  and  require  open- 
ings so  large  as  to  be  incompatible  ,v\%h.  the  solidity 
of  the  appliance,  a  bracketed  plaster  appliance  should 
be  used.  This  is  constructed  according  to  the  funda- 
mental rules  of  fixation,  that  is  to  say,  it  will  fix  the 
trunk  and  the  elbow.     That  the   arm  may  be  well 


Fig,  41. — Bracketed  plaster  : 
details  of  its  construction.  Dia- 
gram of  the  axillary  triangle 
and  its  incorporation  with  the 
plaster  jacket  and  the  casing 
enveloping  the  limb.  The  figures 
indicate  the  order  in  which  the 
bandage  is  applied.  The  hand 
should  be  enclosed  sufficiently 
to  support  the  wrist. 


sustained  by  a  solid  support,  a  metal  triangle  is  placed 
in  the  axilla,  made  with  a  strip  of  metal  bent  in  two 
places,  or  with  any  other  rigid  supporting  material. 
Each  side  of  this  triangle  is  6  to  7  inches  long. 

The  appliance  will  include  : 

(i)  A  plaster  jacket  firmly  enclosing  the  injured 
shoulder,  made  with  three  or  four  five-yard  bandages. 


396 


TREATMENT   OF   FRACTURES 


(ii)  A  circular  bandage  enclosing  the  limb  from  the 
shoulder  to  the  distal  extremity  of  the  metacarpals 
(three  bandages). 

(iii)  A  triangle  of  sheet  iron,  padded  with  wool  fixed 
on  with  a  gauze  bandage. 

(iv)  An  iron  loop  in  the  form  of  a  bridge.  This  loop, 
the  ends  of  which  are  slightly  raised  in  order  to  pre- 


FiG.  42. — Bracketed  appliance  complete;   a  sling  supports 
the  forearm  and  hand. 

vent  sli]:)ping,  is  supported,  above,  beyond  the  coraco- 
acromial  arch  on  the  line  from  the  shoulder  to  the 
neck,  and  below,  at  a  point  on  the  casing  of  the  arm 
immediately  below  the  wound. 

The  plaster  jacket  is  applied  first,  the  bandage  pass- 
ing over  and  including  the  thoracic  side  of  the  axillary 
triangle.  When  the  latter  is  well  fixed,  the  bandage 
is  passed  over  the  shoulder,  and  describes  figures-of- 


FRACTURES   OF    THE    HUMERUS     31)7 

eight  round  the  axilla  and  the  neck,  then  is  wound 
round  the  arm,  binding  the  humeral  side  of  the 
axillary  triangle  to  it.  This  done,  the  enveloping  of 
the  elbow,  forearm,  and  hand  is  carried  out,  these 
structures  being  fixed  in  the  position  already  indi- 
cated. 

Finally,    the   scapulo-humeral   bracket   is   fixed   in 
place  on  the  plaster  by  another  bandage,  and  nothing 


Fig.  43. — Radiograph  fifteen 
days  after  extensive  sub-perios- 
teal  resection  of  the  shoulder 
done  on  the  fourth  day  in  a 
case  of  extensive  injury  to  the 
epiphysis  and  shaft.  The  out- 
hne  of  the  capsule  and  perios- 
teum of  the  head  is  clearly 
visible. 


Fig.  43a. — Radiograph  of  the 
same  case  four  nnonths  after 
resection  :  complete  cure  was 
obtained  in  two  months,  with- 
out pyrexia  at  any  time.  The 
satisfactory  regeneration  of  bone 
in  the  injured  region  will  be 
noticed.  The  functional  result 
is  excellent. 


remains  but  to  expose  the  region  of  the  wounds  and 
to  trim  the  edges  of  the  plaster. 

(6)  A  case  arrives  in  a  more  or  less  septic  condition, 
suj^purating  profusely,  or  with  local  signs  of  arthritis 
of  the  shoulder -joint.  Immediate  sub-periosteal  re- 
section is  necessary.  It  is  certainly  j)os*ihle,  by 
suitable  incisions,  to  provide  sufficient  drainage  to 
arrest  the  general  symptoms,  but  it  is  impossible  to 


398 


TREATMENT   OF   FRACTURES 


prevent  slow  necrosis  of  the  head  of  the  bone,  which 
is  becoming  isolated  in  the  articular  cavity.  Its  re- 
moval should  not  be  delayed  until  muscles  have  been 
destroyed  and  the  patient's  general  condition  is  bad. 
This  late  secondary  resection  is  necessarily  more 
drastic  than  if  it  had  been  done  immediately,  since 
the  end  of  the  shaft  is  also  usually  diseased.     The 

functional  result  varies 
inversely  with  the  mus- 
cular injury  ;  if  the  mus- 
culature is  still  adequate, 
remarkable  functional 
recovery  may  occur  (figs. 
43  and  44).  The  re- 
generation of  bone  is 
also  almost  always  very 
complete,  if  care  is  taken 
to  preserve  the  perios- 
teum. 

(c)  A  case  arrives  with 
sinuses.  The  first  step 
is  an  X-ray  examination 
which  will  show  accu- 
rately the  real  condition 
of  the  upper  extremity 
of  the  humerus  and  the 
joint.  In  a  few  excep- 
tional cases,  union  will 
have  occurred,  the  joint 
will  have  remained  free, 
and  the  only  trouble  will 
be    superficial     osteitis, 


Fig.  44.  —  Radiograph  four 
months  after  late  sub- periosteal 
resection,  in  the  case  ilhistrated 
in  fig.  39.  A  large  bridge  of  bone 
formed  from  the  periosteum  unites 
the  shaft  witli  the  glenoid  cavity, 
and  the  shoulder  is  ankylosed. 
I  did  not  attempt  to  restore  move- 
ment on  account  of  the  complete 
disorganisation  of  the  muscles. 


with  or  without  seques- 
tra. Treatment  should  be  limited  to  scraping  the 
bone  clean  and  removing  sequestra. 

But  more  often  there  is  no  callus  and  the  fracture  is 
suppurating,  there  are  numerous  dead  splinters  in  the 
neighbourhood  and  in  the  joint,  and  the  upper  fragment 


FRACTURES    OF    THE    HUMERUS     •YM) 

is  obviously  inflamed.  Resection  is  necessary  ;  the 
usual  incision  is  made  without  regard  to  the  position 
of  the  sinuses.  Every  effort  is  made  to  preserve  the 
periosteum  as  completely  as  possible.  It  will  often 
be  necessary  at  the  first  dressing  to  sacrifice  the 
biceps  tendon,  which  is  gangrenous  and  giving  rise  to 
suppuration. 

[d]  A  case  is  seen  with  pseudarthrosis.  Sometimes 
there  is  but  little  functional  trouble,  and  there  should 
be  no  interference,  treatment  being  directed  to  deve- 
lopment of  the  muscles.  In  other  cases  there  is  con- 
siderable trouble  :  if  sepsis  is  not  clinically  evident, 
if  the  upper  fragment  is  prolonged  downwards  by 
a  splinter  from  the  shaft,  and  if  the  joint  is  free, 
osteo-synthesis  may  be  attempted  after  trimming  of 
the  fragments,  but  the  operation  is  difficult  to  carry 
out  and  the  result  doubtful.  If  this  intervention  is 
not  attempted  or  has  failed,  a  prosthetic  appliance 
must  be  used. 

(e)  A  case  is  seen  with  a  flail-arm. — It  will  be 
understood  that  there  are  two  categories  of  flail-  or 
useless  arms  :  the  active  form  in  which  the  upper 
limb  swings  freely  in  repose,  but  can  be  fixed  by 
muscular  contraction  when  a  movement  is  to  be  carried 
out,  and  the  passive  form  in  which  the  whole  upper 
limb  hangs  absolutely  useless. 

The  active  flail-arm  is,  in  fact,  what  it  is  attempted 
to  produce  by  excision  of  the  head  and  part  of  the 
shaft.  The  result  is  generally  satisfactory,  often  re- 
markably so,  even  after  extensive  resection  (fig.  43a), 
and  there  is  no  occasion  for  interference. 

On  the  other  hand,  a  passive  flail-arm  is  a  serious 
infirmity,  which  not  only  destroys  the  function  of  the 
shoulder,  but  greatly  interferes  with  that  of  the  fore- 
arm and  hand.  Contrary  to  what  is  usual  in  the 
elbow,  it  is  not  alwaj's  possible  in  this  case  to  re- 
develop by  prolonged  massage  sufficient  muscle  to 
support  the  arm.     Recourse  should  then  be  had  to 


400  TREATMENT    OF    FRACTURES 

the  use  of  a  prosthetic  ai^pliance,  which  gives  a  very 
fair  result. 

Attempts  may  also  be  made  to  improve  the  situa- 
tion by  effecting  humero-glenoidal  fixation,  humero- 
clavicular  suspension,  or  the  double  humero-coraco- 
acromial  suspension  wJiich  Oilier  practised. 

I  have  no  experience  of  these  and  cannot  say  what 
is  actually  effected.  But  according  to  the  fullest 
information  I  possess,  I  believe  this  solution  infinitely 
preferable  both  to  any  grafting  that  the  surgeon  might 
be  tempted  to  effect  (graft  from  the  fibula)  and  to 
osteoplasty  by  reduplication  of  the  humerus,  which 
is  technically  much  more  difficult  and  apjDarently  less 
reliable  in  its  results. 


n.   Sub-deltoid  Fracture 

1.  Anatomical  Features. — This  is  a  fracture  situ- 
ated in  the  upper  third  of  the  humerus,  of  such  a 
nature  that  the  lower  fragment  of  the  shaft  is  abso- 
lutely or  nearly  intact,  below  the  insertion  of  the 
deltoid.  The  fracture  is  often  comminuted ;  the 
shell-fragment  or  bullet  has,  as  it  were,  entirely  re- 
moved the  bone  below  the  insertion  of  the  muscle, 
with  the  result  that  the  deltoid  acts  unrestrainedly  on 
the  upper  fragment. 

In  other  cases  there  are  large,  very  oblique  splinters, 
but  this  is  less  common. 

As  a  rule  there  are  no  radiating  fissures  or  accom- 
pany mg  vascular  and  nervous  lesions. 

2.  Physiological  Features. — The  deltoid  pulls 
strongly  on  the  upper  fragment  and  abducts  it ;  its 
lower  end  is  thus  found  to  be  raised  and  deflected 
outwards,  with  the  medullary  canal  directed  outwards, 
while  the  lower  fragment  remains  in  place,  embraced 
by  the  brachialis  anticus.  The  angle  formed  by  the 
two  fragments,  which  is  about  45°,  is  incomplete  on 


FRACTURES   OF    THE   HUMERUS     401 


its  inner  and  posterior  aspect ;   it  is  here  that  small 
fragments  and  bone  dust  are  found. 

In  some  fractures  the  opposite  displacement  occurs, 
the  upper  fragment  being  pulled  strongly  inwards 
and  internally  rotated  (fig.  46).  This  displacement  is 
due  to  partial  laceration  of  the  deltoid  insertion,  giving 
predominance  to  the  action 
of  the  pectoralis  major ; 
this  rnuscle  then  pulls  the 
upper  fragment  into  a 
position  such  that  fixation 
should  be  effected  with  the 
elbow  and  arm  made  fast 
to  the  trunk,  and  vertical 
extension  by  weights  as 
indicated  in  fig.  60. 

3.  Course.  —  Infective 
lesions  here  are  similar  to 
those  met  with  in  any 
other  region ;  what,  how- 
ever, characterises  this  frac- 
ture is  the  impossibility  of 
manual  reduction ;  the 
angulation  of  the  principal 
fragments  persists  indefi- 
nitely, if  it  is  not  corrected 
by  placing  the  lower  frag- 
ment, which  alone  can  be 
moved,  in  direct  line  with 
the  upper.  Pseudarthrosis  sometimes  results,  par- 
ticularly in  comminuted  fractures  and  when  the 
wound  suppurates  ;  the  infection  then  destroys  the 
activity  of  the  periosteum  which  alone  can  produce 
material  to  bridge  the  gap. 

When,  on  the  other  hand,  the  infection  is  slight  (in 
fracture  by  bullets  causing  only  small  cutaneous 
wounds),  union  occurs,  but  with  marked  deformity 
(antero-external  angulation)  and  marked  shortening. 


Fig.  45. — Low  sub-deltoid 
fracture  :  the  position  is 
usually  higher  in  the  shaft. 


402 


TREATMENT    OF    FRACTURES 


Fig.  46. —  Frac- 
ture with  adduction 
of  the  upper  frag- 
ment, due  to  action 
of  the  pectoralis 
major.  Radiograph 
taken  on  arrival  at 
the  hospital,  after 
evacuation  in  a 
splint. 


4.  Indications  for  early  Treatment. — Sub-peri- 
osteal  esquillectomy  is  necessary  here  as  elsewhere  in 
order  completely  to  prevent  sepsis  ;  the  thick  mus- 
cular layer  surrounding  the  injury  makes  the  danger 
of  the  development  of  serious  infection  in  a  closed 
cavity  very  serious. 

In  performing  the  operation,   the  fracture  should 

preferably  be   ap- 
proached    by     an 
antero-internal  in- 
cision, the  muscle 
fibres  being  sepa- 
rate   in    order    to 
reach  the  bone ;  a 
posterior     incision 
might  result  in 
severance    of    the 
circumflex    nerve, 
and    therefore    in 
permanent  paraly- 
sis of  the  deltoid, 
which  should    be  avoided.     The 
entry   and    exit   wounds    should 
be  cleaned,  but  drainage  is  carried  out 
through  the  incision.     Bone  debris  should 
be  removed  with  minute  care,  the  muscle 
being  often  riddled  with  it.     In  this,   however, 
there  is  nothing  peculiar. 

The  only  peculiarity  in  the  treatment  of  this 
type  of  fracture  is  the  position  in  which  it  is  put 
up.  The  lower  fragment,  which  is  movable, 
whereas  the  other  is  not,  is  brought  upwards  and 
outwards  into  line  with  the  upper  fragment,  and  the 
arm  is  immobilised  in  this  position. 

This  can  best  be  done  by  means  of  a  plaster  apparatus 
constructed  in  one  of  the  following  ways,  both  of 
which  I  have  employed  several  times. 

{a)  If  the  wounds  are  large.     The  appliance  should 


/!^'" 


FRACTURES    OF    THE    HUMERUS      403 


leave  the  arm  exposed,  merely  supporting  the  lower 
fragment  in  line  with  the  upper.  This  plaster  consists 
of  five  pieces  : — • 

(i)  A  thoracic  belt  which  is  applied  first. 

(ii)  Two  braces,  one  as  broad  as  the  palm  of  the 
hand,  and  passing  over  the  uninjured  shoulder ;    the 


r  ^ 


Fig.  47. — Plaster  apparatus  for  immobilising  the  arm  in  an  ab- 
ducted position.  The  two  small  sketches  are  copies  of  radiographs 
taken  before  and  after  application  of  the  apparatus  in  the  particular 
case  illustrated.  The  figures  indicate  the  order  of  application  of  the 
different  pieces  of  the  appliance. 

other  much  wider  in  its  centre  where  it  covers  the 
injured  shoulder. 

(ill)  A  trough  for  the  forearm,  embracing  the  elbow 
and  passing  some  distance  above  it.  A  plaster  band- 
age is  wound  round  these  different  pieces  to  unite 
them. 


404  TREATMENT   OF   FRACTURES 

(iv)  A  metal  splint  {e.g.  a  small  wire  splint  such  as  is 
found  in  the  field-service  outfits)  bent  at  an  acute 
angle  in  the  middle,  which  is  incorporated  horizontally 
in  the  chest  plaster  by  means  of  a  plaster  bandage 
(figs.  47  and  48).     Its  object  is  to  support  the  lower 

fragment  in  the 
position  of  abduc- 
tion. 

For  the  first  few 
days  three  or  four 
wooden  splints  are 
fixed  by  strapping 
over  the  dressing, 
to  secure  better 
immobilisation  of 
the  fragments,  as 
is  shown  in  fig. 
60. 

This      excellent 
appliance  is   kept 
in     place    until 
union    occurs.     If 
YiQ^  48.  it  should  deterior- 

ate, another  of  the 
same  type  is  made,  or  the  appliance  described  below 
may  be  employed. 

(6)  //  the  wounds  are  not  extensive,  an  apparatus  is 
made  with  plaster  bandages  in  the  following  way  : 

A  well-fitting  plaster  jacket  is  first  made,  covering 
the  injured  shoulder  (three  or  four  bandages  5  yards 
in  length),  then  one  is  made  to  cover  the  upper  limb, 
supported  in  a  position  of  abduction. 

To  maintain  it  in  this  position  I  used  to  consider 
a  bent  iron  loop  necessary,  surrounding  the  elbow 
and  fixed  to  the  thorax.  For  some  time  I  have  re- 
placed this  by  a  sort  of  plaster  bridge,  made  of  several 
thicknesses  of  bandage,  and  kept  stretched  between 
the  elbow  and  chest  by  an  assistant  until  it  has  set. 


FRACTURES   OF    THE    HUMERUS      405 

A  few  turns  of  a  plaster  bandage  make  this  bridge 
solid  and  unite  it  with  the  rest  of  the  appliance  ;  it 
is  much  lighter  when  made  thus. 

It  is  safer  to  include  a  second  plaster  support  con- 
necting the  elbow  with  the  lower  edge  of  the  jacket 
(see  fig.  49). 

A  rigid  axis  of  wood  or  cane  can  be  incorporated 


FiQ.  49. 


with  great  advantage  in  the  two  plaster  bridges  :  an 
ordinary  ruler  makes  arn  excellent  support.  It  is  also 
possible  to  use  the  arrangement  described  on  p.  393  . 

If  the  patient  has  to  be  kept  in  bed,  the  best  method 
is  the  suspension  appliance  which  will  be  found  de- 
scribed in  fig.  65,  p.  428 ,  traction  being  exerted  in 
a  position  of  abduction,  which  is  easily  arranged. 


40fi  TREATMENT   OF   FRACTURES 

5.  Indications  in  cases  already  under  Treat- 
ment OR  SEEN  AT  A  LATER  STAGE. — [a)  An  evacuated 
case  in  which  esquillectomy  has  not  been  done  is  going 
on  ivell  at  the  end  of  five  or  six  days.  If  there  is  no  in- 
fection, no  suppuration,  and  no  foreign  body  present, 
it  is  only  necessary  to  immobilise  the  limb  in  a  good 
position. 

{h)  A  case,  in  which  there  has  been  an  incomplete 
operation,  or  none  at  all,  is  still  suppnratiiig  profusely 
when  seen  during  the  first  three  weeks.  After  X-ray 
examination,  by  which  the  position  and  features  of 
the  lesion  are  determined,  free  esquillectomy  and 
drainage  is  carried  out,  and  the  limb  is  immobilised  as 
after  a  primary  operation. 

(c)  A  case  is  found  to  be  suppurating,  but  union  is 
beginning.  An  operation  on  the  bone  is  probably 
inadvisable.  The  best  course  is  merely  to  drain  and 
remove  free  splinters,  but  it  is  hot  the  time  to  inter- 
fere with  adherent  splinters  and  to  injure  the  infected 
bony  area  ;  at  this  stage  any  course  that  is  in  the 
least  drastic  is  dangerous.  It  is  better  to  wait  for 
the  later  stage  of  sinus  formation,  when  the  patient's 
condition  is  less  feeble  probably  because  the  medullary 
canal  has  become  shut  off. 

{d)  A  case  is  seen  ivith  a  sinus. — This  is  almost 
always  due  to  a  free  splinter,  which  is  more  or  less 
enclosed  and  unable  to  escape.  There  is  rarely  a 
central  sequestrum,  and  the  operation  is  generally 
easy. 

(e)  A  case  is  seen  with  pseudarthrosis . — This  is  almost 
always  due  to  want  of  reduction,  and  the  condition 
justifies  forcible  reduction  with  metallic  osteosynthesis 
by  Lambotte's  method  or  by  wiring. 

m.   Fracture  of  the  Middle  of  the  Shaft 

1.  Anatoinucal  Features. — Of  all  the  fractures  of 
the  upper  limb,  these  are  the  most  frequent. 

Two  principal  types  exist,  that  accompanied  by  large 


FRACTURES    OF    THE    HUMERUS      }o7 

splinters  and  that  marked   by   small   splinters ;  each 
of  these    exhibits    the   general  features  discussed  on 

p.  ^81 

In  the  large-s23lintered  type,  which  appears  more 
common  than  the  other,  there  is  either  roughly  the 
butterfly-wing  arrangement  described  by  military 
surgeons,  or  extensive  lateral  splintering,  opening  the 
medullary  canal  and  impossible  to  describe  owing  to 
its  variety  (fig.  5)  ;  often  in  this  case,  the  missile,  being 
spent,  stops  in  the  medullary  canal ;  the  majority  of 
the  splinters  are  originally  adherent  and  fixed,  but 
free  particles  of  bone  are  constantly  found  in  the 
medullary  canal. 

In  the  comminuted  type,  nearly  the  entire  segment 
of  bone  injured  is  shattered  into  debris  and  projected 
into  the  muscles,  or  left  as  adherent  splinters  rotated 
upon  their  own  axes  :  the  largest  fragments  are  scarcely 
more  than  2  inches  long,  and  they  are  the  least 
numerous  ;  in  fact,  little  is  left  between  the  two 
fragments  of  the  shaft,  and  the  actual  gap  is  almost 
always  about  2  inches  wide. 

The  peculiarity  of  these  two  types  is  the  extreme  fre- 
quency of  nervous  lesions,  and  particularly  of  radial 
{musculo-spiral)  paralysis.  It  is  difficult  to  give  an 
exact  figure,  but  this  complication  is  found  in  one  out 
of  four  cases,  if  not  in  one  out  of  three.  The  nerve  is 
most  usually  severed,  and,  to  judge  by  my  own 
observations,  generally  in  the  classical  position,  that 
is  to  say,  in  the  musculo-spiral  groove. 

Paralysis  of  the  median,  or  of  the  ulnar,  or  of  both 
'may  also  be  found. 

The  nerve  injury  is  sometimes  a  complete  sever- 
ance, sometimes  lateral  laceration,  sometimes  simple 
contusion  with  interstitial  haemorrhage. 

In  a  number  of  cases  there  is  assCociated  injury  to 
the  lung,  the  same  projectile  having  fractured  the 
humerus  and  passed  into  the  thorax. 

2.  Physiological  Features. — In  comminuted  frac- 


408  TREATMENT    OF    FRACTURES 

tures  there  are  none  ;  owing  to  the  extensive  destruc- 
tion of  bone  and  rupture  of  surrounding  muscles,  little 
displacement  of  the  fragments  occurs. 

In  large-splintered  fractures  it  is  unusual  for  the 
upper  fragment  to  tilt  forwards  (action  of  the  deltoid) 
and  perforate  the  brachialis  anticus.  This  only  occurs 
in  the  high  fractures  studied  in  the  preceding  section. 
On  the  other  hand,  the  lower  fragment  is  pulled  up 
by  the  triceps  and  has  a  slight  tendency  to  backward 
and  upward  displacement ;  this  upward  m.ovement  is 
often  scarcely  perceptible,  and  a  more  prominent 
feature  is  angulation  with  its  apex  pointing  backwards. 
A  single  radiograph  is  not  sufHcient  to  make  this  out ; 
the  topogra2:)hy  of  a  fracture  can  only  be  appreciated 
from  two  plates,  one  lateral,  one  antero-posterior.  In 
any  case,  however,  the  displacement  is  slight,  the 
fragments,  enclosed  by  the  brachialis  anticus,  remain- 
ing in  place. 

3.  Course. — We  will  put  aside  grave  and  rapidly 
developing  sepsis,  causing  death  from  gas  gangrene, 
or  necessitating  early  amputation  for  acute  osteomye- 
litis. A  few  uncommon  fractures  *  are  seen  at  the  base, 
which  run  a  simple  course  from  first  to  last  without 
operation,  in  which  the  shell-fragment  traversed  the 
bone  without  leaving  anything  behind  it :  such  cases 
are  exceptional. 

After  an  operation  reduced  to  what  is  strictly 
necessary  to  prevent  the  most  serious  septic  phenomena, 
persistent  suppuration  generally  follows,  with  puru- 
lent tracks  along  the  biceps  and  brachialis  anticus. 
The  local  development  of  suppuration  necessitates 
repeated  drainage  ;  repeated  searches  are  necessary 
for  dead  splinters,  which  make  their  way  towards  the 
orifice  of  the  wound,  and  the  patient,  after  fifteen  or 

♦  I  remind  the  reader  that  fractures  by  a  bullet  which  has  caused 
"  punctiform  "  cutaneous  wounds  are  not  within  the  scope  of  the 
present  study,  and  that  in  such  cases  an  uneventful  course  leading 
to  satisfactory  union,  after  fixation  and  extension,  is  the  rule. 


FRACTURES    OF    THE    HUMERUS      409 

eighteen  months,  shows  with  pride  and  satisfaction 
all  the  pieces  of  bone  which  have  been  removed  from 
his  wound. 

At  the  end  of  two  or  three  months  of  suppuration 
the  fracture  may  be  in  one  of  the  following  different 
conditions  : 

(a)  Consolidation  and  complete  healing. — If  con- 
tinuous extension  has  been  well  effected,  reduction  is 
generally  satisfactory  and  the  anatomical  result  is 
good  ;  physiologically,  the  power  of  the  functional 
muscles  is  more  or  less  reduced  by  inflammatory  sclero- 
sis and  a  long  period  is  required  for  the  re-establish- 
ment of  their  normal  contractility,  but  the  final 
result  would  be  very  passable  if  the  callus  were  not 
large,  and  often  misshapen  :  it  is  almost  always  a 
badly  formed  callus,  bearing  trapes  of  the  infected 
medium  from  which  it  has  been  developed.  This  is 
not  without  importance  ;  when  an  operation  is  per- 
formed in  the  immediate  neighbourhood  of  the  frac- 
ture with  the  object  of  freeing  or  suturing  the  radial 
nerve,  all  the  tissues  round  the  bone  are  found  to  be 
lardaceous  and  fibrous  ;  often  in  dissecting  the  nerve 
on  the  surface  of  the  bone,  small  superficial  osseous 
cavities  are  opened,  enclosing  a  small  sequestrum 
surrounded  by  more  or  less  serous  but  not  virulent 
pus.  The  whole  region  gives  the  impression  of  patho- 
logical tissues  of  poor  quality.  In  fact,  recurrent 
fractures  are  not  unusual ;  it  would,  indeed,  be 
surprising  if  they  were. 

Briefly,  an  apparently  good  result,  but  with  every 
chance  of  trouble  in  the  future. 

(6)  Consolidation  with  superficial  osteitis. — After 
five  or  six  months  there  remains  a  small  sinus  covered 
by  a  superficial  spab  and  continually  oozing  small 
quantities  of  sero-purulent  fluid.  It  is  customary  to 
wait  for  this  to  heal  of  its  own  accord.  I  have  seen 
several  which  persisted  for  fourteen,  sixteen,  or  eighteen 
months,  and  in  the  majority  of  cases,  associated  radial 


410  TREATMENT    OF    FRACTURES 

(rriasculo-spiral)  paralysis  had  been  left  without 
intervention  because  the  wound  was  not  aseptic. 
Usually  a  small  area  of  superficial  osteitis  is  concerned, 
or  a  small  marginal  cavity  enclosing  a  sequestrum 
which  cannot  escape.  Cure  can  usually  be  effected 
by  a  simple  operation. 

(c)  Union  by  a  redundant  callus  with  a  central 
cavity. — This  is  the  typical  case  of  pathological  con- 
solidation described  on  p.  302  Passing  through  the 
thick  periosteal  bone,  a  sinus  leads  into  a  cavity,  at 
each  end  of  which  is  a  mass  of  condensing  osteitis 
closing  the  medullary  canal.  The  lesion  is  not  spon- 
taneously curable,  and  is  difficult  to  cure  by  operation. 
The  prospect  for  these  patients  is  poor,  and  the  surgeon 
should  not  be  sanguine  of  functional  recovery.  There 
is  every  likelihood  of  frequent  outbreaks  of  sepsis 
necessitating  successive  operations. 

[d)  Pseudarthrosis. — The  absence  of  union  (as  apart 
from  its  delay)  occurs  in  two  conditions,  in  each  by  a 
different  process. 

In  comminuted  fractures,  in  which  a  segment  of  the 
shaft  has  been  pulverised,  the  marrow  is  destroyed, 
and  the  periosteum  very  nearly  so.  Unless  asepsis  is 
assured,  the  remains  of  the  bone-forming  tissue  on  the 
under  surface  of  the  periosteum  is  destroyed  by  the 
infection  :  rarefying  osteitis  develops  in  the  ends  of 
the  shaft,  a  certain  amount  of  fibrous  and  lardaceous 
tissue  becomes  interposed  between  them,  and  no 
spontaneous  fusion  is  possible.  This  is  pseudarthrosis 
by  destruction  of  the  tissues  which  should  effect 
repair. 

In  large-splintered  fractures  it  often  happens  that 
when  the  appliance  is  fitted,  the  splinters  which  have 
been  left  in  place,  closing  in  on  the  long  axis  of  the 
bone  as  a  result  of  continuous  extension,  enclose  a 
more  or  less  isolated  fragment  of  muscle  which  becomes 
interposed  between  the  fragments  of  the  shaft,  and 
mechanically   prevents   spontaneous    repair.     At    the 


FRACTURES   OF    THE    HUMERUS     411 

same  time  the  marrow  is  destroyed  by  infection,  the 
periosteum  is  rendered  inactive,  and  the  ends  of  the 
shaft  undergo  necrosis.  In  a  case  of  this  kind  I  was 
able  to  remove  a  piece  of  bone  which  demonstrated 
this  very  well.  It  was  built  up  in  the  following  way  : 
in  the  centre  was  a  piece  of  the  brachialis  anticus  J  in. 
in  length,  caught  below  on  a  sequestrum  completely 
covering  the  soft  and  spongy  lower  end  of  the  shaft, 
and  surmounted  by  another  semi-annular  sequestrum 
covering  the  upper  extremity  of  the  shaft,  which  was 
also  the  seat  of  rarefying  osteitis. 

These  two  types  of  pseudarthrosis  are  not  of  rare 
occurrence,  and  the  majority  seen  at  the  base  are  of 
this  kind ;  it  is  wrongly  concluded  that  the  humeral 
periosteum  is  comparatively  non-fertile.  The  fact  of 
the  matter  is  that  amputation  is  less  frequently  per- 
formed for  fractured  humerus  than  elsewhere  since  the 
phenomena  of  sepsis  are  less  serious  in  the  humerus 
than  in  the  thigh  where  the  muscular  covering  is  much 
thicker,  and  also  less  severe  than  in  the  forearm  and 
leg,  where  the  presence  of  tendons  and  their  sheaths 
may  lead  to  serious  secondary  complications. 

4.  Indications  for  early  Treatment. — There  is 
only  one  way  of  assuring  a  sure  and  regular  course 
towards  a  definite,  anatomically  and  physiologically 
perfect,  cure  and  of  preventing  all  the  troublesome 
developments  described  above  :  that  is  to  perform 
free  sub-periosteal  esquillectomy  as  early  as  possible. 
This  prevents  the  development  of  any  signs  of  infec- 
tion, and  thoroughly  clears  the  bony  surfaces.  Perfect 
reduction  of  the  fracture  is  thus  facilitated,  with- 
out allowing  the  slightest  possibility  of  muscular  inter- 
position ;  at  the  same  time  all  the  elements  necessary 
to  repair  are  preserved  in  the  wound. 

When  this  operation  is  carefully  performed  in  the 
correct  manner,  that  is,  with  the  sharp  rugine,  the 
constant  result  is  permanent  asepsis  ;  this  facilitates 
fixation  of  the  fracture  in  simple  appliances  by  which 


412         TREATMENT    OF    FRACTURES 

reduction  is  easily  effected  by  continuous  extension. 
The  three  stages  of  treatment,  preventive  disinfection, 
reduction,  and  fixation,  are  carried  through  without 
hindrance ;  the  patient  may  be  evacuated  very  soon, 
and  union  occurs  rapidly  (thirty-five  days  to  two 
months). 

5.  Operative  Technique. — {a)  In  Esquillectomy. — 
(i)  Method  of  approach. — The  topography  of  the  frac- 
ture and  the  position  of  any  missiles  should  previously 
have  been  determined  by  X-ray  examination,  or  if 
possible  from  a  radiograph.  There  are  two  available 
ways  of  exposing  the  fracture,  according  or  not  as  the 
size  and  position  of  the  wound  provides  a  way  of 
access. 

If  the  exit  wound  is  large,  and  not  in  immediate 
contact  with  vessels  or  nerves,  the  track  of  the  pro- 
jectile is  followed  in  the  reverse  direction,  the  cutaneous 
orifice  being  enlarged  if  necessary,  and  the  track  care- 
fully cleaned  ;  two  retractors  are  placed  in  position, 
and  any  lacerated  or  dead  tissue,  all  free  bony  frag- 
ments, and  all  foreign  bodies,  are  removed  with  forceps. 
A  bistoury  is  then  used  to  excise  any  fascia  or  muscle 
that  it  may  be  necessary  to  remove  in  order  to  prevent 
closure  over  the  fracture  or  the  retention  of  any 
obviously  contused  tissue.  This  will  sometimes  in- 
volve enlargement  of  the  cutaneous  incision.  There 
should  be  no  hesitation  in  doing  this  ;  the  external 
wound  is  of  little  importance,  the  main  point  being 
to  discover  all  the  lesions  and  thoroughly  to  expose 
the  fracture. 

If  the  cutaneous  wounds  are  small,  inconveniently 
placed,  or  in  contact  with  nerves  or  the  brachial  artery, 
or  in  such  a  position  that  subsequent  care  of  the 
wound  will  be  difficult  {e.g.  an  axillary  wound),  the 
bone  is  approached  by  the  route  of  election,  that  is 
to  say,  by  an  incision  over  the  outer  side  of  the  arm 
between  the  biceps  and  the  outer  head  of  the  triceps. 

The  bone  being  exposed,  an  intact  periosteal  sheath 


FRACTURES    OF    THE    HUMERUS       413 

will  generally  be  found,  particularly  in  large-splintered 
fractures  ;  this  is  incised  along  an  adherent  fragment, 
the  incision  being  begun  at  the  point  where  the  shaft 
ends,  and  the  rugine  is  used  carefully  to  free  the 
periosteum  on  each  side  of  the  incision  ;  in  this  way 
it  is  easy  in  the  majority  of  cases  to  free  a  consider- 
able periosteal  cavity  without  actually  having  removed 
any  adherent  piece  of  bone. 

(ii)  Extent  of  the  Esquillectomy. — Following  the 
usual  rules  indicated  on  p.  345  free  and  loosely  adherent 
splinters  are  next  removed,  and  when  the  region  of 
the  fracture  has  been  cleared,  a  further  investigation 
should  be  made.  The  object  of  this,  as  has  been  stated 
before,  is  to  expose  any  area  of  medullary  contusion, 
in  order  to  explore  the  injury  completely  and  to  leave 
behind  nothing  suspicious. 

In  large-splintered  fractures,  this  will  often  lead 
to  the  removal  of  a  very  adherent  postero-external 
splinter  lodged  beneath  the  triceps  and  corresponding 
in  position  to  the  origins  of  the  inner  and  outer  heads 
of  that  muscle,  to  which  it  is  firmly  adherent;  very 
near  to  this  is  the  radial  nerve  in  the  musculo-spiral 
groove  or  immediately  below  it.  It  is  of  great  im- 
portance to  detach  this  very  carefully  :  I  make  a 
regular  practice  of  doing  so  when  such  a  fragment 
exists,  regarding  this  as  the  best  means  of  avoiding 
subsequent  involvement  of  the  nerve  in  the  callus, 
an  accident  that  is  very  liable  to  occur,  since  the  nerve 
generally  lies  in  immediate  contact  with  the  fissure, 
and  crosses  the  fragment  like  a  bridge.  In  doing  this, 
there  is  no  fear  of  injuring  the  nerve  if  the  periosteum 
is  respected  ;  the  process  is  identical  with  that  of 
liberating  the  ulnar  nerve  in  resection  of  the  elbow 
joint :  in  this  way  the  nerve  is  pushed  beyond  the 
interosseous  gap,  and  will  not  be  involved  in  any 
subsequent  periosteal  proliferation.  Further,  during 
this  freeing  of  the  nerve,  a  small  missile  is  sometimes 
found  concealed  by  one  edge  of  the  fragment,  which 


414  TREATMENT    OF    FRACTURES 

otherwise  would  certainly  have  escaped  notice.  I  am 
not  speaking  of  the  very  small  free  splinters  which 
may  also  be  found,  and  whose  presence  explains  those 
little  residual  abscesses  often  found  near  the  bone 
during  a  later  operation  for  radial  paralysis. 

Finally,  after  the  operation,  the  only  bone  left  in 
the  injured  region  are  the  two  pointed  ends  of  the 
shaft,  in  contact  at  their  apices  :  this  I  believe  to  be 
an  excellent  result.  An  examination  of  the  injury 
to  the  bone  will  show  that  the  space  left  empty  by 
the  removal  of  splinters  is  enclosed  by  a  hollow 
cylinder  of  periosteum,  the  mould,  as  it  were,  of  the 
future  callus.  In  comminuted  fractures,  there  are 
usually  at  the  periphery  short  and  adherent  splinters 
connected  with  the  shaft  above  and  below  ;  any  of 
these  should  be  removed  with  the  rugine  which  are 
sit?Uated  near  vessels  or  nerves,  particularly  the  radial 
nerve.  When  the  esquillectomy  is  completed,  there  is 
an  interfragmentary  gap  of  about  1|  inches,  in  which 
hang  fragments  of  periosteum  :  the  ends  of  the  shaft 
are  generally  oblique  and  rather  ragged.  Gentle 
cleaning  of  the  medullary  canal  with  a  small  curette 
should  complete  the  operation.  For  this  purpose  it 
is  not  generally  necessary  to  proceed  further  up  than 
the  area  exposed  by  the  removal  of  adherent  frag- 
ments. It  is  advisable  to  remove  the  sharp  points  of 
the  ends  of  the  shaft  with  cutting  forceps;  in  doing 
this,  great  care  should  be  taken  not  to  interfere  with 
the  periosteum  by  pushing  it  aside  before  applying 
the  bone  forceps ;  otherwise,  what  has  previously 
been  preserved  is  lacerated,  and  there  is  a  risk  of 
spoiling  the  work  of  the  rugine. 

Dressings. — The  wounds  of  entry  and  exit  being 
cleaned  according  to  the  usual  rules,  and  missiles  in 
the  neighbourhood  of  the  fracture  being  removed,  the 
wound  is  plugged  with  aseptic  gauze.  There  should 
be  no  strip  of  dressing,  and  above  all,  no  drainage 
tube,  passing  through  the  wound  from  one  side  to  the 


FRACTURES    OF    THE    HUMERUS     415 


other  :  gauze  is  placed  very  loosely  in  the  medullary 
cavity,  in  the  operative  incision,  and  in  all  other 
wounds,  which  should  be  left  widely  open.  All  sutur- 
ing should  be  avoided ;  there  is  no  advantage  in 
partially  closing  the  cutaneous  wound  at  each  end, 
as  is  so  often  done  :  it  is  never  cutaneous  healing 
which  retards 
cure,  but  deep 
healing,  which 
suture  will  not 
hasten. 

For  fixation 
pur  p  o  s  e  s  ,  I 
merely  flex  the 
elbow  and  apply 
the  arm  to  the 
chest,  which  is 
padded  with 
sterilised  wool, 
and  bind  it 
there  with  soft 
bandages,  a  n 
ar  r  a  n  g  e  m  e  n  t 
identical  with 
Velpeau's  ban- 
dage employed 
after  reduction 
of  a  dislocated 
shoulder.  Care 
should  be  taken 
to  pla^e  a  small 
pad  of  absorbent 
wool  sprinkled  with  sterilised  talc  in  the  axilla,  and 
to  pad  the  elbow  well.  This  bandage  is  left  in  place 
for  several  days  when  all  goes  well;  I  have  some- 
times not  touched  the  dressing  before  the  eighth  day. 

I  always  change  the  first  dressing  under  an  anaes- 
thetic (ethyl  chloride)  :    in  this  way  pain  is  avoided, 


Fia.    50a. — Large- 


splintered 
with    bony- 
caused    by 
fragment. 


fracture 
fissures, 
a    shell- 


FiG.  505.  —  Ra- 
diograph showing 
the  result  of  early- 
sub  -  periosteal  es- 
quillectomy  and 
continuous  exten- 
sion applied  to  the 
elbow. 


416 


TREATMENT   OF   FRACTURES 


the  wound  can  be  examined  better,  small  omissions 
in  the  operation  can  be  made  good,  and  the  gauze 
can  be  placed  more  exactly  where  it  is  required. 
If   anything   necessitates   its   being  repeated  later 

(pain,  considerable  oozing, 
or  pyrexia),  a  similar 
bandage     should     be    re- 


Fi«.  51, — Total  sub-periosteal  Fig.    52.— Result    after    two 

esquillectomy     was     performed  months ;      the      wounds      have 

eighteen  hotirs  after  the  occur-  closed,  after  daily  heliotherapy, 
rence  of  this  fracture. 

applied,  and  the  same  temporary  fixation  arranged  : 
it  is  advisable  not  to  use  a  permanent  appliance  un- 
til a  regular  course  of  recovery  is  certain  ;  moreover, 
well  cleaned  recent  wounds  progress  well  with  infre- 
quent dressing.  If  the  case  has  to  be  evacuated 
rapidly,  the  dressing  should  be  performed  on  the  day 
previous  to  that  fixed  for  the  evacuation. 

For  transport  a  plaster  trough  covering  the  ehoulder 
with  two  small  thoracic  flaps  should  be  applied.     But 


FRACTURES   OF    THE   HUMERUS     4ir 


this  is  only  a  travelling  appliance,  to  be  removed  on 
arrival,  and  is  not  intended  for  treatment  (fig.  53). 

ip)  Permanent  Reduction  and  Immobilisation. — When 
free  esquillectomy  has  been  done,  reduction  practically 
follows,  and  the  fracture  will  unite  in  the  correct  posi- 
tion after  simple  fixation  in  a  plaster  splint,  provided 
that  the  correspondence  of  the  long  axes  of  the  frag- 
ments has  been  verified  by  the  X-rays.  But  if  the 
quantity  of  bone 
lost  is  not  great, 
continuous  ex- 
tension gives  a 
better  result 
since  the  reduc- 
tion is  more  per- 
fect, the  frag- 
ments are  kept 
well  apart  and 
therefore  there 
is  no  shortening. 

Let  us  ex- 
amine the  two 
cases : 

(i)  When  there 
is  limited  loss  of 
bone.  Here  there 
is  juxtaposition 
of  the  fragments 
without  loss    of 


Fig,  53. — Plaster  apparatus  for  travelling. 


length  in  the  bone-;  over-riding  is  possible  and  re- 
duction is  necessary. 

Continuous  extension  and  fixation  can  be  effected 
by  one  and  the  same  apparatus,  such  as  Delbet's 
appliance,  or  one  of  its  modifications  (Leclercq's  appli- 
ance) or  with  Alquier's  crutch. 

In  Delbet's  appliance  the  extension  is  exerted  above 
by  means  of  a  curved  metallic  axillary  support,  padded 
with  cotton  wool,  and  below  b}/  a  semicircular  metal 


418 


TREATMENT    OF    FRACTURES 


plate  over  the  upper  end  of  the  forearm,  the  elbow 
being  kept  flexed  at  right  angles  by  a  plaster  bandage. 
A  hollow  rod  is  hinged  to  the  forearm  plate,  and  within 
it  slides  a  solid  rod  connected  with  the  axillary  crutch. 
Traction  is  exerted  by  a  spiral  spring  which  forces 

the  two  shafts  apart,  and  these 
latter  are  pierced  by  holes  into 
which  a  pin  can  be  introduced, 


Fig.  54. — Delbet's 
appliance. 


Fig.   55. — Delbet's  appliance 
in  place. 


and  by  means  of  this  the  spring  can  be  shortened  and 
extension  consequently  regulated. 

This  appliance  is  excellent ;  sometimes  it  is  a  little 
painful,  particularly  in  fractures  high  up,  where,  on 
account  of  correction  being  more  difficult,  there  is  a 
tendency  to  employ  an  undue  amount  of  extension, 
but  the  reduction  of  serious  displacements  can  be 
effected  by  it.  It  has  the  further  advantage  of  leav- 
ing the  injured  region  exposed,  and  of  allowing  slight 


FRACTURES    OF    THE    HUMERUS      419 


movements  of  abduction  of  the  arm,  and  of  supination 
and  pronation  of  the  forearm. 

When  the  fracture  has  been  properly  set  and  the 
correct  pressure  ascertained,  the  care  of  the  aj)paratus 
is  simple ;  attention 
should  be  given  to  the 
condition  of  the  skin  of 
the  axilla,  to  which  a 
zinc  oxide  paste  should 
be  applied  as  a  pre- 
cautionary measure  in 
fat  subjects.  Particular 
attention  should  be  de- 
voted to  the  position  of 
the  forearm,  which 
should  remain  flexed  at 
a  right  angle ;  if  the 
angle  becomes  obtuse, 
the  support  slips  and 
extension  ceases.  The 
appliance  should  not  be 
removed  until  union  has 
occurred. 

Leclerq  has  modified  Delbet's  apparatus,  rendering 
it  interchangeable  for  the  right  and  left  arm.  The 
semicircular  axillary  support  which  he  employs  is 
wider  and  longer,  and  derives  support  also  from  the 
thorax  ;  the  lower  plate  is  also  wider.  The  principle 
is  the  same  ;  the  results  are  equally  good  ;  the  disad- 
vantage— that  the  appliance  cannot  be  improvised — 
is  the  same.  War  surgery  requires  that  it  should  be 
possible  to  construct  the  necessary  appliances  on  the 
spot,  by  simple  means  and  from  elementary  materials. 

Alquier's  appliance  fulfils  these  conditions  :  work- 
ing upon  Delbet's  idea  and  the  form  of  his  apparatus, 
he  has  given  a  very  practical  and  interesting  solution 
of  the  problem. 

His  appliance  can  be  constructed  very  easily  any- 


FiG.  56. — Leclerq' s  appliance. 


420 


TREATMENT   OF    FRACTURES 


(r\ 


where  and  in  a  few  moments,  from  two  iron  slats  each 
rather  longer  than  the  arm.  The  upper  part  of  one 
of  these  is  divided  longitudinally  into  two  pieces  5|  in. 
in  length,  which  are  then  separated  and  twisted  in 
such  a  way  as  to  from  a  sort  of  curved  crutch.  The 
lower  part  remains  as  a  straight  shaft,  and  is  pierced 
with  four  holes  through  which  bolts  may  be  passed. 

A  slot  is  cut  out  in  the  upper 
part  of  the  second  slat,  while 
the  lower  part  is  bent  up  in 
the  form  of  a  loop.  The 
crutch  is  padded  with  cotton 
wool  surrounded  by  a  flannel 
bandage  and  covered  with 
mackintosh.  The  appliance 
is  then  ready.  To  apply  it, 
a  circular  plaster  bandage  is 
first  applied  to  the  forearm 
from  a  point  slightly  above 
the  elbow  down  to  the  hand, 
fixing  the  elbow  at  right 
angles  ;  it  should  be  moulded 
round  the  projections  of  the 
elbow.  When  the  plaster  is 
dry,  the  padded  crutch  is 
placed  in  the  axilla,  the 
straight  shaft  is  placed  paral- 
lel to  the  internal  surface  of 
the  arm,  and  the  semicircle 
of  the  lower  piece  is  then 
fitted  to  the  (posterior)  under  aspect  of  the  elbow, 
to  the  outline  of  which  it  should  correspond  exactly  ; 
the  straight  shaft  passes  upwards  in  contact  with 
the  arm  and  with  the  upper  piece.  A  few  turns  of 
a  plaster  bandage  fix:  the  curved  piece  to  the  elbow, 
and  when  the  plaster  is  set,  traction  is  applied.  For 
this  purpose  a  weight  of  4  kilogrammes  is  suspended 
from  the  flexed  elbow  for  half  an  hour,  a  short  counter- 


Fia.  57. — Alquier's  ap- 
pliance, with  the  crutch 
padded. 


FRACTURES   OF    THE   HUMERUS      421 

extension  being  applied  in  the  axilla.  When  muscular 
contraction  is  overcome  and  the  fracture  reduced,  the 
nuts  are  screwed  up,  and  nothing  further  is  necessary 
but  to  remove  the  extension  and  counter-extension. 


Figs.  58  and  59. — Method  of  arranging  the  bands  for  extension. 

I  regard  this  appliance  as  one  of , the  best,  if  not  the 
best,  of  all  that  have  been  suggested.  It  is  simple, 
reduces  well,  does  not  interfere  with  dressing,  and  is 


422 


TREATMENT    OF    FRACTURES 


perfect  for  evacuation  :   in  fact,  I  consider  it  the  ideal 
appliance  for  the  front. 

At  the  base,  the  purposes  of  treatment  can  be  ful- 


filled in  an  equally 
perfect  way,  and 
still  more  simply. 
In  these  frac- 
tures, particularly 
after  esquillec- 
tomy,  the  dis- 
placement is  not 
marked,  since  the 
fragments  are  not 
under  the  in- 
fluence of  power- 
ful muscular  ac- 
tion ;  further, 
when  the  patient 
is  standing,  gra- 
vity itself  tends  to 
reduce  angulation ;  in  fact,  the  lower  fragment  is 
virtually  in  continuous  extension  ;  exaggeration  of 
this  tendency,  effected  by  suspending  a  weight 
above  the  elbow,  is  enough  to  reduce  the  displace- 


FiG.  60. — Extension  effected,  with  a 
weight  of  1,200  grammes. 


FRACTURES    OF    THE    HUMERUS     423 

merit.  On  the  other  hand,  permanent  continuous  ex- 
tension, if  it  may  so  be  described,  is  not  necessary 
for  the  maintenance  of  reduction,  and  intermittent 
continuous  extension  (to  use  paradoxical  terms)  is 
sufficient  if  repeated  regularly.  This  was  so  in  the 
case  of  oblique  fractures  in  peace-time  ;  it  is  equally 
true  of  war  fractures.  I  have  regularly  employed  a 
very  simple  continuous  extension  procedure  based  on 
these  theories,  which  is  in  constant  use  at  Lyons  for 
simple  fractures.  Like  Berard  and  Desgouttes,  who 
have  also  used  it,  I  have  obtained  excellent  results. 

With  this  apparatus,  extension  is  only  active  when 
the  patient  is  standing  and  the  elbow  is  against  the 
side,  but  experience  shows  that  this  is  sufficient. 

The  apparatus  is  simple.  It  consists  in  applying 
continuous  extension  by  weights  above  the  elbow, 
and  in  keeping  the  fragments  immobilised  by  fixing 
three  or  four  narrow  wooden  splints  over  the  dressing 
by  means  of  a  bandage  which  holds  everything  to- 
gether and  immobilises  perfectly  (see  fig.  60). 

There  are  several  methods  of  effecting  extension  : 

(a)  The  weight  of  the  lower  fragment  may  simply 
be  increased  by  winding  round  it  a  sheet  of  lead  (800 
to  1,000  grammes),  in  the  form  of  a  figure-of-eight, 
the  upper  loop  of  which  surrounds  the  humerus  and 
the  lower  the  elbow. 

(/3)  A  collar  in  the  shape  of  a  figure-of-eight  may 
be  applied,  identical  with  Hennequin's  used  for  frac- 
tures of  the  thigh  ;  this  is  made  of  linen  or  similar 
material,  and  a  suitable  weight  is  hung  from  the 
lower  loop. 

(7)  Lastly,  regular  traction  may  be  effected  by 
means  of  adhesive  strapping  :  this  is  the  method 
which  I  usually  employ  ;  it  is  more  exact  since  the 
pull  can  be  exerted  in  a  slightly  anterior  or  posterior 
direction  when  X-ray  examination  shows  this  to  be 
necessary. 

The  patient  being  seated,  and  the  elbow  flexed  at  a 


424  TREATMENT   OF   FRACTURES 

slightly  acute  angle,  a  loop  of  strapping  is  first  applied 
in  the  shape  of  a  U,  the  vertical  limbs  passing  verti- 
cally upwards  on  each  side  of  the  elbow  and  arm  as 
far  as  possible,  exactly  parallel  to  the  long  axis  of  the 
shaft.  To  ensure  more  perfect  adhesion,  the  upper 
bands  may  be  cut  into  short  strips  and  splayed  out 
on  the  arm.  This  done,  the  vertical  loop  is  fixed  by 
means  of  a  circular  piece  of  strapping  over  which  the 
upper  limbs  of  the  U  are  reflected.  A  third  and  very 
long  piece  describes  a  figure-of-eight,  the  upper  loop 
passing  round  the  humerus,  the  lower  surrounding  the 
elbow.  A  circular  band  of  strapping  round  the  arm 
fixes  the  upper  loop,  while  the  lower  is  united  with 
the  loop  of  the  vertical  U.  It  is  from  this  that  the 
weight  is  suspended.  The  final  appearance  of  the 
appliance  is  shown  in  fig.  60. 

A  pad  of  wool  should  be  placed  in  the  axilla  to 
force  the  upper  fragment  slightly  outwards.  The 
forearm  is  supported  by  a  sling.  At  night  the  weight 
is  supported  or  removed,  to  be  replaced  in  the  morning. 

When  the  dressing  needs  replacement,  it  is  suffi- 
cient to  remove  the  immobilising  splints  without  inter- 
fering with  the  extension  ;  carried  out  in  this  way, 
dressing  is  painless,  if  the  patient  is  seated — that  is,  if 
extension  is  active. 

The  initial  weight  used  should  be  500  grammes, 
gradually  increased  to  1,200  grammes. 

The  simplicity  of  this  appliance  should  not  deter 
one  from  using  it :  the  radiographs  reproduced  here 
(figs.  61  and  62)  show  a  perfect  reduction  effected  by 
it.  The  only  disadvantage  is  that  it  cannot  be  used 
for  cases  that  are  obliged  to  remain  in  bed  ;  in  such 
cases  it  would  be  satisfactory  merely  to  exert  a  hori- 
zontal pull,  using  the  bar  of  a  chair  or  any  other  similar 
arrangement  as  a  pulley,  but  a  suspension  appliance 
such  as  will  be  described  later  is  preferable. 

When  the  formation  of  callus  begins,  after  thirty 
to  forty  days,  the  wounds  are  usually  reduced  in  size 


FRACTURES    OF    THE    HUMERUS     425 


and  require  dressing  only  at  long  intervals  ;  at  this 
stage  I  replace  the  extension  by  a  plaster  trough,  in- 
cluding a  cap  moulded  on  the  shoulder  (fig.  51),  but  I 
have  occasionally  retained  the  extension  ajjpliance 
until  complete  cure  was  effected. 

(ii)   When  there  is  an  interfragmentary  loss  of  hone 
caused  by  the  missile  and  cleared  out  by  esquillectomy, 


Fig.  61. — Fracture  of  the  hu- 
merus caused  by  a  bullet,  with 
piuictiform  cutaneous  wounds ; 
before  continuous  extension  was 
applied. 


Fig.  62. — Result  of  continuous 
extension  by  simple  application 
of  a  weight  to  the  elbow  (figure- 
of-eight-  arrangement  of  strap- 
ping). This  radiograph  was 
taken  eight  days  after  that  in 
fig.  61. 


continuous  extension  is  unnecessary;  reduction  consists 
in  immobilising  in  good  position,  for  which  plaster  is 
sufficient :  simple  traction  exerted  on  the  plaster  while 
it  is  drying  brings  the  fragments  into  line,  without 
the  possibility  of  anything  becoming  interposed 
between  them. 

If  the  wound  is  not  too  large  and  runs  an  aseptic 


426 


TREATMENT    OF    FRACTURES 


course,  a  fenestrated  plaster  bandage  may  be  applied, 
similar  to  that  described  on  p.  394 .  As  a  rule,  how- 
ever, the  wound  in  the  soft  jjarts  is  extensive  and 
requires  for  its  care  comparative  freedom  of  the  arm, 
while  it  is  better  also  that  regular  exposure  to  the  air 
and  sun  should  be  possible. 

After  many  experiments  with  interrupted  plasters,  I 

have  abandoned  these  in 
favour  of  an  appliance  that 
has  given  me  consistently 
good  results  for  the  last  six 
months.* 

Two  plaster  bandages  and 
three  tarlatan  splints  each 
consisting  of  twelve  thick- 
nesses are  prepared  ;  one  of 
these  is  passed  round  the 
chest  and  closely  applied 
to  the  prominence  of  the 
shoulder  (an  essential  point) ; 
another  is  used  as  a  trough 
for  the  forearm,  passing 
behind  the  elbow  and  a 
variable  distance  up  the  hu- 
merus ;  the  third  is  used  as 
a  sling  supporting  the  fore- 
arm splint  (iig.  63). 

Sometimes  before  and 
during  the  fitting  of  the  appliance  it  will  be  found 
well  to  apply  continuous  extension  to  the  elbow  by 
means  of  a  weight  and  a  figure-of-eight-shaped  collar, 
described  on  p.  421  . 

A  large  quantity  of  rather  thin  plaster  paste  is  pre- 
pared, and  the  first  step  is  to  apply  the  large  support 

*  Since  this  was  written  (June  1916)  I  have  more  and  more  gener- 
ally used  a  simple  external  trough  for  the  arm,  dressing  the  wound 
at  long  intervals.  The  results  have  been  excellent.  On  the  other 
hand,  I  have  seen  in  use  the  appHance  of  Alquier  described  above, 
and  I  think  it  is  preferable  to  the  piaster  described  here. 


Fi(-     63. 


FRACTURES    OF    THE    HUMERUS     427 


obliquely  across  the  chest,  moulding  it  well  to  the 
contours  by  well-placed  depressions,  and  passing  it 
over  the  shoulder.  The  slight  final  adjustments  re- 
quired for  exact  adaptation  should  not  be  hurried 
(hence  the  necessity  for  a  thin  paste).  The  trough 
for  the  forearm  is  then  applied,  the  elbow  being  flexed 
and  the  hand  pronated,  with  the  thumb  directed  up- 
wards. The  edge  of  the 
splint  should  go  as  far 
as  possible  up  the  pos- 
terior aspect  of  the  el- 
bow, and  the  latter 
should  be  firmly  sur- 
rounded by  it.  The 
sling  is  then  adjusted 
in  a  good  position  and 
fixed  by  a  safety  pin. 

When  this  has  been 
done  and  the  position 
of  the  arm  has  been 
verified  and  the  frag- 
ments of  the  humerus 
have  been  found  to  be 
well  in  line,  the  three 
parts  of  the  appliance 
are  united  with  plaster 
bandages.  When  all  is 
complete,  only  a  half 
to  two-thirds  of  the  arm 
is  exposed,  and  the  two 

articular  ends  of  the   humerus  are    absolutely  fixed 
(fig.  64). 

This  appliance  is  extremely  convenient,  and  if  well 
constructed,  gives  perfect  results.  After  early  sub- 
periosteal esquillectomy,  union  generally  occurs  at  the 
end  of  six  weeks,  and  the  appliance  can  be  kept  in 
place  for  the  whole  of  this  time. 

For  patients  obliged  to  remain  in  bed,  a  suspension 


Fig.  G4. 


428 


TREATMENT    OF    FRACTURES 


appliance  is  the  best.  Continuous  horizontal  exten- 
sion is  first  applied  in  line  with  the  long  axis  of  the 
arm  by  a  weight  of  1,200  or  1,500  grammes  ;  the  arm 
is  then  suspended  by  two  triangular  bandages  wide 


Fig.  65.* 

enough   to   support   the   fragments    well ;    these   two 
bandage-supports  are  fixed  to  a  small  piece  of  wood 

*  For  the  sake  of  clearness,  the  bandage  shngs  have  been  repre- 
sented as  rather  narrow. 


FRACTURES    OF    THE    HUMERUS     429 

suspended  from  a  pulley  by  a  cord  carrying  the  weight 
necessary  to  counterbalance  the  arm  (usually  2  kilo- 
grams) ;  the  forearm,  bandaged  firmly  over  cotton 
wool,  is  suspended  from  a  second  j^ulley  (see  fig.  65). 

6.  Treatment  of  cases  seen  at  a  late  stage  or 
ALREADY  UNDER  TREATMENT  — Five  possibilities  should 
be  considered  : 

{a)  A  Case  progresses  well  after  no  operation  or  after 


Fig,  66.  —  Large  -  splintered 
fracture  of  the  humerus.  Total 
sub-jjeriosteal  esquillectoxny  was 
performed  during  the  second  day. 


Fig.  67. — Result  after  two 
months  of  eontirmous  extension 
by  weights  applied  to  the  elbow  ; 
there  was  no  pyrexia. 


an  inadequate  one. — The  wound,  for  instance,  dates 
from  five  or  six  days  previously,  and  the  dangerous 
period  has  passed ;  there  is  no  suppuration  and  no 
swelling.  Such  a  case  is  very  unusual.  If  no  foreign 
body  can  be  detected  by  X-rays  within  or  near  the 
bone,  it  is  sufficient  to  employ  continuous  extension 
by  the  methods  explained  above  (traction  applied 
above  the  elbow  through  adhesive  strapping). 


430  TREATMENT    OF    FRACTURES 

The  course  will  be  that  of  a  bullet-fracture  with 
punctiform  skin  orifices,  i.e.  that  of  a  simple  fracture. 

If  a  foreign  body  is  present,  the  steps  to  be  taken 
depend  upon  its  situation.  If  it  is  intra-osseous,  ex- 
ploratory sub-periosteal  esquillectoniy  should  be  under- 
taken in  order  to  remove  it  :  delayed  sepsis  is,  in 
fact,  very  probable,  and  its  develo])ment  should  be 
prevented ;  removal,  too,  is  easy  in  this  early 
stage,  whereas  it  is  very  difficult  when  it  necessitates 
penetrating  to  the  centre  of  a  more  or  less  recent 
callus. 

If  the  missile  is  outside,  but  near  the  bone,  the 
surgeon  may  either  wait  for  the  development  of  a 
small  abscess  which  commonly  forms,  before  removing 
it,  or,  after  localisation,  may  remove  it  at  once  ;  this 
latter  course,  in  my  opinion,  is  decidedly  preferable. 

(b)  A  fracture,  after  an  inadequate  operation,  becomes 
subsequently  profoundly  septic. — After  X-ray  examina- 
tion, and  localisation  of  the  foreign  body,  if  one  is 
jjresent,  sub-periosteal  esquillectomy  and  drainage 
should  be  carried  out  as  early  as  possible  ;  this  is 
conducted  exactly  in  the  same  way  as  the  operation 
in  the  early  stage.  Eight  to  ten  days  after  the  opera- 
tion, the  condition  of  the  fracture  should  be  deter- 
mined by  a  radiograph.  If  the  wound  is  suppurating, 
or  any  debris  remains  overlooked,  it  should  be  re- 
moved, and  subsequent  clinical  asepsis  will  usually 
be  assured  in  eight  to  fifteen  days.  The  fracture  will 
unite  normally  without  the  tracking  of  pus  to  points 
remote  from  the  wound,  and  without  muscular  sclero- 
sis. Sometimes,  however,  after  three  or  four  weeks, 
superficial  healing  will  apparently  be  arrested  or  a 
little  pus  will  appear  ;  this  leads  to  the  conclusion  that 
there  is  slight  osteitis  of  one  end  of  the  shaft,  the 
marrow  of  which  had  been  infected.  After  con- 
firmation by  X-rays,  it  will  usually  be  easy  with 
forceps  to  find  a  small  and  still  adherent  inflamed 
sequestrum,   the  removal   of   which  will  immediately 


FRACTURES    OF    THE    HUMERUS     431 

abolish  these  complications  (see  figs  28,   29,  and  30, 
pp.338  339  ). 

Union  usually  occupies  a  month  and  a  half,  and 
complete  cutaneous  healing  two  months. 

(c)  A  case  is  seen  at  a  late  stage  {after  a  7nonth)  sup- 
purating more  or  less  freely. — The  advisability  of  an 
operation  on  the  bone  is  very  doubtful ;  osteomyelitis 
has  seriously  affected  the  region  of  the  fracture,  which 
should  be  interfered  with  as  little  as  possible  ;  ab- 
scesses should  be  incised,  and  the  wound  drained,  but 
only  completely  free  splinters  should  be  removed. 

Esquillectomy  on  the  lines  advocated  above  would 
very  possibly  give  rise  to  acute  septic  phenomena, 
and  would  injure  the  region  without  completely  clear- 
ing it.  It  is  better  to  refrain,  immobilise,  drain,  and 
wait,  meanwhile  expecting  a  sinus  to  form. 

(d)  A  C2se  is  seen  ivith  a  sinus. — Instead  of  blind 
exploration  with  the  probe,  an  X-ray  examination 
from  two  aspects  should  be  made  to  determine  the 
cause  of  the  sinus  ;  sometimes  it  will  be  a  foreign  body 
which  must  be  extracted,  more  often  it  is  a  patch  of 
superficial  osteitis  with  a  peripheral  cavity  partially 
enclosing  a  small  sequestrum.  A  central  cavity  of 
variable  size  is  almost  always  found  ;  the  sides  of  this 
must  be  widely  cut  away,  the  edges  bevelled,  and  the 
interior  displayed  as  completely  as  possible,  after 
removal  of  sequestra,  if  any  are  present.  With  this 
in  view,  the  bone  should  preferably  be  approached 
from  its  outer  aspect,  not  forgetting  the  presence  of 
the  radial  nerve  in  the  lower  third  of  the  arm. 

(e)  A  case  is  seen  with  pseudarthrosis . — There  should 
be  no  confusion  between  pseudarthroses  and  exten- 
sive losses  of  bone  deliberately  produced  in  a  case  of 
extensive  crushing  of  the  bone,  when,  the  nerves  and 
vessels  being  intact,  it  has  been  desired  to  avoid  ampu- 
tation. 

The  term  pseudarthrosis  is  only  applied  if  union 
fails    to    occur   between   fragments   reasonably   close 


432  TREATMENT    OF    FRACTURES 

together.  When  a  great  length  of  bone  has  been  lost, 
union  is  impossible  ;  conditions  are  unfavourable  for 
grafting,  and  it  is  better,  at  least  temporarily,  to  fit 
a  prosthetic  appliance. 

Pseudarthroses,  on  the  other  hand,  should  be  treated 
by  immediate  operation  ;  it  is  in  no  way  necessary 
to  wait  for  complete  superficial  healing  of  the  wound 
before  uniting  the  bone.  It  has  seemed  to  me  that 
the  operation  is  more  successful  when  the  bones  are 
infected  and  osteitic  than  when  they  are  atrophied, 
worn  away,  and  devitalised.  I  believe  it  is  well,  when 
possible,  to  send  the  patient  for  a  preliminary  stay  at 
the  seaside,  or  to  treat  him  by  sunlight,  in  order  to 
strengthen  the  musculature,  restore  tone  to  the  skele- 
ton, and  disinfect  the  tissues.  The  time  employed  in 
this  physio-therapeutic  cure  is  not  lost,  and  it  is  largely 
to  this  that  I  attribute  my  habitual  success  in  treat- 
ing pseudarthroses  of  the  humerus. 

I  believe  that,  from  the  operative  point  of  view, 
osteosynthesis  is  preferable  to  grafting.  Gunshot 
wounds  are  very  bad  media  for  a  bone-graft ;  failures 
have  been  and  will  be  numerous  :  on  the  contrary, 
osteosynthesis  by  Lambotte's  plate  or  by  wiring  gives 
perfect  results  in  the  humerus. 

When  the  operation  has  been  decided  on,  the  region 
of  the  fracture  is  very  widely  exposed  by  a  long  inci- 
sion external  to  the  vessels  and  nerves.  The  ends  of 
the  bone  are  freed  with  the  rugine  for  a  considerable 
distance  in  each  direction,  and  every  effort  must  be 
made  to  preserve  as  extensive  a  sheath  of  periosteum 
as  possible  ;  these  extremities  are  resected  to  a  suffi- 
cient extent  to  leave  them  symmetrical  and  consisting 
of  healthy  bone  ;  the  ideal  is  to  find  a  normal  medul- 
lary canal  on  section.  All  the  interfragmentary 
fibrous  tissue  is  excised,  after  which  the  extremities 
are  fastened  in  position  by  one  or  two  Lambotte  plates 
and  long  screws. 

The  wound  is  left  open  and  simply  plugged.     It 


FRACTURES    OF    THE    HUMERUS     433 

is  undoubtedly  possible  in  certain  cases  to  sew  up  the 
incision  again,  and  effect  a  cure  by  first  intention.  But 
in  addition  to  these  fortunate  cases,  there  are  many 
serious  failures — suppuration,  separation  of  the  bones, 
recurrence  Of  osteitis  and  a  return  to  the  condition  of 
pseudarthrosis.  If  the  wound  is  left  open,  no  risks 
are  run ;  progress  is  aseptic,  and  dressing  is  required 
only  at  infrequent  intervals.  I  apply  a  plaster  trough 
and  leave  the  dressing  in  place  as  long  as  possible  ; 
at  the  end  of  seven  or  eight  weeks  the  plates  may 
easily  be  removed  when  union  has  begun. 

IV.    Supra-condylar  Fracture  of  the  Elbow 

1 .  Anatomical  Features. — These  common  fractures 
occur  immediately  above  the  lower  epiphysis  of  the 
humerus.  They  are  usually  comminuted  ;  frequently 
one  of  the  fragments  of  the  shaft  tapers  gradually  to 
a  pronounced  point,  which  is  directed  forwards  in  the 
case  of  the  lower  fragment,  and  backwards  if  it  forms 
part  of  the  upper. 

There  are  often  fissures  running  towards  the  joint ; 
these  sometimes  end  close  to  it  without  splitting  the 
epiphysis  ;  more  frequently  they  reach  the  cartilage. 
If  the  injury  is  very  violent,  the  fracture  distinctly 
involves  the  joint,  the  humeral  condyles  are  broken 
and  the  cartilage  is  shattered  ;  there  is,  in  fact,  a  con- 
dition constituting  a  definitely  articular  fracture. 

There  are  sometimes  associated  nervous  lesions, 
usually  of  the  ulnar. 

2.  Physiological  Features. — There  is,  as  a  rule, 
no  displacement ;  the  lower  fragment  inclines  slightly 
forwards,  and  sometimes  this  is  all ;  it  is,  however, 
serious,  since,  owing  to  this  anterior  inclination,  union 
is  difficult  and  the  fracture  is  liable  to  pseudarthrosis. 

There  is  often  also  separation  of  the  lower  fragment 
due  to  the  weight  of  the  limb,  which  carries  the  fore- 
arm and  elbow  either  outwards  or  inwards. 


434 


TREATMENT    OF    FRACTURES 


3.  Course. — The  characteristic  feature  of  this  frac- 
ture is  the  presence  of  fissures  running  down  towards 
the  joint.  They  are  unimportant  if  the  fracture  re- 
mains aseptic,   since  their  repair  and  disappearance 

then  follow  very  rapidly ;  if,  how- 
ever, there  is  any  infection,  it  will 
invariably  extend  to  the  joint,  and 
osteomyelitis  in  the  region  of  the 
fracture  is  soon  complicated  by 
arthritis,  at  first  serous  and  later 
suppurative. 

If  the  fracture  has  not  been 
cleaned,  and  the  infection  is  not 
virulent,  a  paradoxical  develop- 
ment may  be  observed  :  the  ar- 
thritis ends  in  ankylosis,  and  the 
fracture,  failing  to  unite,  ends  in 
pseudarthrosis.  I  have  examined 
three  cases  in  which  this  curious 
result  has  been  observed  ;  it  was 
favourable  in  one  case,  poor  in 
another,  and  deplorable  in  the 
third  (fig.  68). 

But  more  often  infection  of  the 
joint  develops  in  a  serious  way, 
and  necessitates  secondary  resec- 
tion, if  not  amputation.  Resection 
may  give  a  good  result,  if  it  is 
kept  strictly  sub-periosteal  and  if 
the  injuries  do  not  extend  too  far 
up  the  limb  ;  sometimes,  however, 
some  inches  of  the  shaft  are  de- 
stroyed, and  resection,  though 
necessary,  leaves  a  flail-elbow. 

4.  Indications  for  early  Treatment  and  de- 
tails OF  Technique. — The  only  means  of  avoiding 
the  serious  early  and  troublesome  later  developments 
enumerated  above  (severe  articular  infection,   supra- 


FiG.  G8.— Radio- 
graph of  a  case 
which  had  suppura- 
ted for  eight  months 
without  oioeration  ; 
numerous  sequestra 
were  ehminated 
spontaneously.  The 
elbow  was  ankylosed 
in  extension. 


FRACTURES    OF    THE    HUMERUS     435 

epiphyseal  pseudarthrosis)  is  to  ])erform  early  com- 
plete sub-periosteal  esquillectomy  which  will  permit 
exploration  of  the  fracture  and  an  aseptic  subsequent 
course. 

All  other  operations  are  uncertain  in  their  results 
and  leave  the  joint  in  danger. 

Method  of  approach. — The  best  method  of  exposing 
the  region  widely  is  to  make  a  free  incision  posteriorly 


FiCt.  09.  —  Supra  -  epiphyseal 
fracture  of  the  elbow ;  joint 
intact. 


Fig,  70. — Radiograph  after 
early  sub-periosteal  esquillec- 
tomy ;  asepsis  resulted.  Case 
evacuated  in  satisfactory  con- 
dition in  fifteen  days  (June  1915). 


in  the  median  lino  through 
the  triceps.  Two  retrac- 
tors enable  the  surgeon  to  inspect  the  fracture  and  act 
as  may  be  necessary  :  all  fragments  of  bone  are 
removed  and  every  effort  is  made  to  preserve  as 
much  periosteum  as  possible.  When  the  region  has 
been  cleaned,  it  will  sometimes  be  well  to  trim  the 
two  extremities  of  the  shaft  wdth  a  saw,  in  order  to 
produce  even  surfaces  in  the  region  of  which  aseptic 
development  will  be  more  easy.    If  there  is  a  splinter- 


436 


TREATMENT   OF   FRACTURES 


like  point,  it  should  not  be  sawn  away,  but  the  rest 
of  the  circumference  should  be  an  even  section. 


Fig.  71. — Supra-articular  frac- 
ture of  the  humerus  by  a  shell- 
fragment,  September  2'9th,  1915. 
Total  sub-periosteal  esquillec- 
tomy  performed  on  the  following 
day  with  trimming  of  the  ex- 
tremities with  a  saw.  •  The  radio- 
graph reproduced  above  was  taken 
ten  days  afterwards.  On  Decem- 
ber 1st  the  plaster  was  removed 
and  the  wound  found  to  be  com- 
pletely healed  without  sinuses, 
and  a  radiograph  showed  an  an- 
terior periosteal  callus  uniting  the 
fragments  perfectly.  Flexion  of 
the  elbow  was  limited  by  the  pro- 
jection of  this  block  of  ossification, 
but  flexion  to  beyond  a  right 
angle  was  possible,  and  extension 
to  about  160°. 

avoided,  but  is  very  much 
necessary,  however,  unless 


Fig.  72. — Radiograph  after 
six  months :  flexion  possible 
to  contsiderably  more  than  a 
right  angle  ;  full  extension  ; 
muscular  action  perfect ;  slight 
torsion. 


If  deep  fissures  are 
found,  and  it  is  prob- 
able that  they  extend  to 
the  joint,  they  may  be 
disregarded  if  the  opera- 
tion is  being  performed 
in  ap'  early  stage.  If 
infection  is  already  evi- 
dent, its  extension  to 
the  joint  may  still  be 
to  be  feared.  Ii  is  not 
the  injury  to  bone  is  very 


FRACTURES   OF    THE    HUMERUS      437 

extensive,  to  perform  resection  of  the  joint  at  once, 
since  a  favourable  course  is  still  possible.  If  the  op- 
posite is  the  case,  there  should  be  no  hesitation  in 
performing  this  operation,  but  the  periosteum,  capsule, 
and  muscular  insertions  must  be  preserved  carefully. 
By  an  "exaggerated"  sub-periosteal  operation  I  was 
able,  in  a  case  of  this  kind,  to  obtain  regeneration  of 
the  shaft  and  epiphysis  to  the  extent  of  about  4|  in., 
with  very  satisfactory  functional  play  of  the  elbow. 

The  operation  of  esquillectomy  and  trimming  with 
the  saw  being  completed,  fixation  should  be  effected 
by  a  posterior  plaster  trough  with  the  elbow  fully 
flexed  :  the  best  reduction  can  be  obtained  in  this 
position.  I  have  never  employed  any  other  nlaster 
but  the  posterior  form,  and  I  find  it  decidedly  prefer- 
able to  interrupted  appliances  for  strict  immobilisation 
of  a  fracture  the  course  of  which  is,  as  a  rule,  very 
simple  after  careful  esquillectomy.  The  plaster  is 
removed  for  each  dressing,  which  may  be  delayed  for 
an  average  of  at  least  seven  or  eight  days. 

Union  occurs  with  considerable  rapidity,  although 
the  periosteum  of  this  region  is  not  very  fertile  ;  it 
has  generally  been  effected  in  my  own  cases  within  a 
month  or  two. 

5.  Treatment  of  cases  seen  at  a  later  stage, 
OR  ALREADY  UNDER  TREATMENT. — («)  A  Case  is  Seen 
progressing  well. — Rigorous  fixation  in  the  flexed 
position  is  alone  required ;  the  meaning  of  the 
words  "  progressing  well  "  should,  however,  be  well 
understood  ;  this  means  to  say  that  the  wound  is 
absolutely  aseptic,  without  the  slightest  discharge.  If 
there  is  any  suppuration,  secondary  arthritis  (of  which 
no  signs  sometimes  appear  until  the  tenth  or  twelfth 
day)  is  always  to  be  feared,  in  spite  of  favourable 
appearances,  and  immediate  total  esquillectomy  should 
be  performed. 

(b)  A  Case  is  seen  with  a  septic  wound. — Immediate 
total  sub-periosteal  esquillectomy  is  necessary  ;  there 


438  TREATMENT    OF    FRACTURES 

is  no  other  means  of  cleaning  the  region  of  the  frac- 
ture and  preventing  involvement  of  the  joint.  If 
arthritis  is  present,  and  there  are  markedly  infected 
fissures,  strictly  sub-periosteal  resection  of  the  whole 
humeral  epiphysis  should  be  performed.  I  have 
carried  out  this  late  secondary  resection  on  three  occa- 
sions in  cases  evacuated  from  the  front  in  a  seriously 
septic  condition.  Very  complete  periosteal  regenera- 
tion was  obtained  (see  figs.  42,  43,  44,  45  of  Part  I) 
and  the  results  have  been  satisfactory  :  the  arm  was 
firm,  and  a  good  degree  of  the  normal  range  of 
voluntary  movement  was  regained.  As  a  precau- 
tionary measure,  I  applied  a  small  copper  splint  with 
rigid  springs,  to  give  more  fixity  to  the  joint. 

(c)  A  case  is  seen  with  fistulous  osteitis. — Unless  the 
case  is  one  of  superficial  osteitis,  easily  curable  by  a 
small  operation,  resection  of  the  elbow  is  frequently 
necessary. 

[d)  A  case  is  seen  with  pseudarthrosis. — If  there  is  no 
infection,  an  incision  may  be  made  along  the  median 
line  thiough  the  triceps,  and  the  bones  united  by  a 
Lambotte  plate  or  metal  wire,  after  excision  of  the 
interfragmentary  scar-tissue.  I  have  never  had  occa- 
sion to  do  this. 


CHAPTER    XllI 

FRACTURES   OF  THE  FOREARM 

The  treatment  of  fractures  of  the  forearm  cannot  give 
good  results  unless  we  take  into  account  certain  new 
physiological  factors  which  regulate  the  mechanical 
conditions  under  which  the  forearm  and  hand  perform 
their  functions,  since  these  factors  ought  to  direct  the 
treatment  before  and  during  the  formation  of  the 
callus. 

The  treatment  of  fractures  undoubtedly  demands  a 
clear  comprehension  of  local  physiological  conditions 
in  any  region  in  order  to  attain  its  object,  which  is 
the  most  perfect  functional  recovery  possible  for  the 
bone  lever  concerned ;  but,  if  necessary,  an  enlight- 
ened empiricism  can  take  the  place  of  physiological 
theory. 

In  the  forearm  this  is  not  so  ;  the  forearm  has  a 
spegial  function,  the  integrity  of  which  is  necessary 
for  perfect  movement  of  the  hand.  The  surgeon  who 
does  not  understand  its  physiology  exactly,  that  is, 
who  does  not  understand  the  precise  mechanism  of 
pronation  and  supination,  will  bft.en  be  responsible 
for  functional  disasters  which  a  better-informed  rr.an 
will  easily  avoid. 

I  consider  this  is  so  important  that  I  shall  depart 
from  the  usual  plan  of  this  little  volume  and  first  ex- 
plain these  fundamental  physiological  views  ;  they 
are  still  little  known,  having  only  recently  been  de- 

439 


440  TREATMENT    OF    FRACTURES 

finitely  stated.*  All  this  knowledge  is  owing  to  Destot, 
who  has  constructed  an  original  theory  of  the  functions 
of  supination  and  pronation  based  upon  radiographic 
analysis  ;  the  problem  is  thus  definitely  solved,  not- 
ably from  the  surgical  point  of  view. 

The  following  points  must  be  clearly  understood 
before  the  surgeon  can  treat  a  fracture  of  the  forearm 
suitably : 

( 1 )  Pronation  and  supination  are  exclusively  effected 
by  the  radius,  which  revolves  round  the  ulna,  carry- 
ing the  hand  with  it ;  the  ulna  only  moves  slightly  in 
an  antero-posterior  direction. 

(2)  The  axis  of  rotation  of  the  forearm  is  oblique  ; 
it  may  be  represented  by  a  line  connecting  the  head  of 
the  radius  with  the  lower  extremity  of  the  ulna. 

(3)  The  head  of  the  radius  revolves  in  a  socket, 
while  the  distal  end  of  the  bone  undergoes  circumfer- 
ential movement  round  the  head  of  the  ulna  :  the 
transformation  of  the  movement  at  the  proximal  end 
(rotation  on  its  own  axis)  to  that  at  the  distal  end 
(circumferential  rotation — i.e.  round  an  external  axis) 
is  caused  by  the  outward  curve  of  the  radius,  and  by 
the  existence  of  a  cervico-diaphysial  angle.  If  the 
shaft  were  straight,  the  movement  would  remain  axial 
and  consist  in  simple  rotation  on  that  axis. 

(4)  During  this  movement,  the  width  of  the  inter- 
osseous space  remains  fixed,  whatever  be  the  position  of 
the  two  bones.  In  radiographs  the  interosseous  space 
appears  wider  in  pronation  than  in  supination,  but 
this  is  an  error  of  projection  :  the  width  of  the  space 
does  not  vary  if  the  plates  exposed  are  placed  parallel 
to  the  plane  of  the  dorsal  aspect  of  the  wrist. 

(5)  The  lower  part  of  the  ulna  is  a  sort  of  pivot 
round  which  the  disttil  extremity  of  the  radius  moves  : 

*  It  has  been  my  first  object  in  this  to  be  as  clear  as  possible, 
referring  the  reader  for  greater  acciiracy  and  fulness  to  the  recent 
treatise  on  fractures  in  which  Tanton,  dealing  with  peace-time  frac- 
tures, gives  a  complete  exposition  of  this  difficult  question,  and  of 
the  work  of  Destot. 


FRACTURES    OF    THE    FOREARM        441 

the  latter  is  so  constituted  that  it  is  always  in  the 
same  degree  of  pronation  or  supination  as  the  upper 
extremity. 

(6)  The  upper  and  lower  radio-ulnar  joints  are,  so 
to  speak,  lateral  hinges,  which  only  maintain  their 
connection  if  the  relative  length  of  the  two  bones  is 
maintained  constant  :  these  joints  are  connected  for 
a  unique  purpose,  and  equality  in  length  of  the  bones 
is  a  necessary  factor  for  their  normal  functioning. 

It  follows  from  these  laws  of  D6stot  that  four  funda- 
mental conditions  control  the  physiology  of  the  forearm : 

Preservation  of  the  outward  curve  of  the  radius, 
permitting  the  movement  of  circumduction  in  the 
lower  extremity ; 

Preservation  of  the  relation  between  corresponding 
points  in  the  head  and  the  distal  extremity  of  the 
radius  ; 

Equality  in  length  of  the  bones  ; 

Preservation  of  the  axis  of  rotation  of  the  forearm. 

It  will  be  understood  from  this  to  what  objects  the 
treatment  of  fractures  of  the  forearm  should  be 
directed. 

Three  varieties  of  fractures  of  the  forearm  must  be 
studied  : 

Fracture  of  both  bones  ; 

Fracture  of  the  radius  only  ; 

Fracture  of  the  ulna  only. 

I.  FRACTURES  OF  BOTH  BONES  OF  THE 

FOREARM 

From  the  point  of  view  of  treatment  three  different 
types  exist : 

Fractures  just  below  the  elbow  joint ; 
Fractures  of  the  shafts  proper; 
Fractures  just  above  the  wrist. 

A.  Fractures  just  below  the  Elbow  Joint. 

1.  Anatomical    Features. — These    fractures    are 


^42  TREATMENT   OF   FRACTURES 

usually  caused  by  great  violence  and  are  comminuted ; 
the  radius  is  broken  in  the  region  of  the  neck,  and  the 
ulna  below  the  sigmoid  cavity,  but  there  is  frequently 
an  internal  splinterlike  projection,  and  the  bicipital 
tuberosity  remains  as  a  part  of  the  upper  fragment. 
In  the  more  simple  type  there  are  no  radiating  fissures, 
but  the  injury  is  frequently  more  complex  ;  in  the 
radius  at  least,  the  cartilage  is  split,  and  the  fracture 
is  therefore  intra-articular.  Fissures  involving  the 
joint  are  less  usually  seen  in  the  ulna,  the  coronoid 
process  and  olecranon  being  very  resistant,  but  long 
fissures  frequently  travel  down  the  shaft  of  the  ulna. 
The  posterior  branch  of  the  radial  nerve  may  be  in- 
jured close  to  the  neck  of  the  radius. 

2.  Physiological  Features. — There  is  little  dis- 
placement of  the  fragments  of  the  ulna  ;  those  of  the 
radius,  however,  exhibit  it  constantly  :  the  head  and 
neck  are  displaced  by  the  biceps,  which  remains,  at 
least  in  part,  inserted  into  the  upper  fragment  in  which 
it  produces  a  combined  movement  of  flexion  and 
supination  :  hence,  the  head  of  the  radius  swings  for- 
ward and  turns  on  its  axis,  while  the  shaft,  under  the 
action  of  the  pronators,  assumes  a  position  of  full 
pronation. 

3.  Course. — ^As  a  result  of  muscular  action,  even  in 
the  most  favourable  cases  when  infection  does  not 
necessitate  early  intervention,  union  of  the  radius  is 
difficult,  and  even  if  it  occurs,  the  two  fragments  con- 
cerned are  generally  displaced  {i.e.  rotated)  in  opposite 
directions. 

In  fact,  there  is  at  least  a  tendency  to  radial  pseud- 
arthrosis,  and  a  risk  of  losing  the  power  of  supination 
and  pronation. 

On  the  other  hand,  particularly  in  mild  cases,  when 
the  bicipital  tuberosity  has  been  smashed  up  and  the 
biceps  consequently  put  out  of  action,  a  radio-ulnar 
synostosis  may  occur,  which  prevents  the  movements 
of  pronation  and  supination.     These  results,  however, 


FRACTURES    OF    THE    FOREARM      443 


are  rare,  for  the  sufficient  reason  that  this  highly 
splintered  region  is  usually  seriously  infected.  The 
infection  extends  to  the  joint  along  the  fissures,  or 
simply  as  a  result  of  contiguity,  and  if  early  acute 
septic  phenomena  have  not  occurred,  marked  suppura- 
tive arthritis  soon  develops  ;  the  upper  fragment  of 
the  radius  undergoes  rapid  necrosis,  and  formidable 
complications  en- 
sue. Unless  resec- 
tion is  performed, 
arthritis  often  ul- 
timately necessi- 
tates amputation. 

Further,  pus 
rapidly  forms  in  the 
region  of  the  ulnar 
fracture  and  ab- 
scesses spread 
among  the  flexors 
and  damage  them 
seriously  (see  p . 
448).  The  flexors 
undergo  necrosis, 
and  there  is  marked 
interference  with 
finger  movements. 
I  have  seen  a  case 

at  a  medical  board  with  ankylosis  of  the  wrist  secondary 
to  a  sub-articular  fracture  of  the  forearm ;  infection 
had  passed  along  the  flexors  and  produced  radio- 
carpal arthritis. 

In  the  rare  cases  which  run  a  favourable  course, 
ankylosis  generally  occurs,  with  a  persistent  osteitis  of 
the  radius  ;  the  power  of  pronation  and  supination  is 
permanently  lost. 

Sometimes  sub-articular  radial  pseudarthrosis  may 
occur  ;  contrary,  however,  to  what  might  naturally 
be  supposed,  there  is  no  functional  improvement. 


Fig,  73. — Radiograph  showing  dis- 
placement of  fragments  in  a  sub- 
epiphyseal  fracture  of  the  radius  and 
ulna  by  a  shell-fragment.  Operation 
twelve  hours  later,  and  cure  effected, 
but  with  radio-ulnar  synostosis.  Flexion 
and  extension  of  the  forearm  are  normal. 
Pronation  and  supination  are  not  pos- 
sible.    The  result  is  remarkable. 


444  TREATMENT    OF    FRACTURES 

In  brief,  suppurative  arthritis,  ankylosis,  pseud- 
arthrosis,  radio-ulnar  synostosis,  and  contraction  of  the 
flexors,  are  the  dangers  in  sub-epiphyseal  fractures  of 
the  bones  of  the  forearm. 

4.  Indications  for  early  Treatment. — The  only 
means  of  avoiding  arthritis  of  the  elbow  joint  consists 
in  completely  cleaning  the  fracture  area  as  early  as 
possible.  For  this  purpose,  whenever  circumstances 
permit,  there  should  be  a  previous  examination  by 
X-rays  or  by  a  radiograph. 

If  the  fracture  is  limited  and  no  fissures  are  visible, 
anatomical  conservation  may  be  attempted,  that  is  to 
say,  only  sub-periosteal  esquillectomy  is  performed. 
The  osteogenetic  power  of  periosteum  near  the  epiphysis 
is,  however,  not  very  great ;  moreover,  the  neck  of  the 
radius  is  displaced,  with  the  fractured  surface  pointing 
upwards,  and  under  these  conditions  a  good  anatomi- 
cal result  is  difficult  to  obtain.  When  union  occurs, 
the  cervico-diaphysial  curvature  of  the  radius,  which 
has  been  discussed  in  connection  with  the  physiology 
of  the  forearm,  is  generally  abolished,  and  the  power 
of  pronation  and  supination  is  lost. 

Owing  to  these  bad  local  conditions,  when  fissures 
extend  to  the  epiphysis,  when  the  damage  is  con- 
siderable, and  particularly  when  operation  is  not 
distinctly  early,  I  believe  that  sub-periostial  resection 
of  the  elbow  is  preferable.  More  extensive  lesions  are 
always  found  in  the  joint  than  were  expected  ;  more- 
over, resection  has  the  advantage  of  ensuring  complete 
prevention  of  serious  infective  developments,  and  of 
enabling  repair  to  take  place  under  aseptic  conditions. 
I  have  obtained  a  very  good  functional  result  in  two 
cases  of  this  kind. 

If,  on  the  other  hand,  the  fracture  involves  the 
shaft  more  than  the  immediate  vicinity  of  the  epiphysis, 
I  believe  simple  esquillectomy  to  be  preferable. 

It  is  on  account  of  these  different  possibilities  that 
a  preliminary  radiograph  is  necessary. 


FRACTURES    OF    THE    FOREARM      445 

Technique. — In  all  cases,  exploration  of  the  region 
should  be  begun  by  an  incision  of  sufficient  length  to 
expose  it  thoroughly.  A  posterior  median  incision, 
slightly  external  to  the  ulnar  crest,  is  preferable  :  by 
this  means  the  condition  of  the  radius  and  ulna  may 
be  easily  investigated.  Clearance  with  the  rugine 
may  be  immediately  begun  on  the  ulna.  Injury  to 
the  flexors  should  be  avoided  as  far  as  possible.  If 
resection  appears  necessary,  it  should  be  total,  that  is, 
the  articular  ends  of  all  three  bones  should  be  re- 
sected :  the  humerus  is  sawn  through  below  the 
epitrochlear-epicondylar  line,  only  the  cartilaginous 
surface  being  removed.  I  explained  in  Part  I,  p.  154 
why  these  rules  should  be  followed  :  the  mutual  adapta- 
tion of  the  bones  is  better,  and  the  functional  results 
are  more  perfect.     I  shall  not  discuss  this  further. 

5.  Treatment  of  cases   first   seen   at  a  late 

STAGE,    OR  ALREADY   UNDER   TREATMENT. — {a)   A   Case 

unoperated  upon  is  doing  well. — ^If  no  foreign  body  is 
present,  intervention  is  not  required,  but  merely 
rigorous  immobilisation,  the  elbow  being  flexed  to 
an  acute  angle  in  order  to  approximate  the  two  frag- 
ments of  the  radius.  I  have  seen  remarkably  good 
functional  results  follow  this  simple  treatment. 

If  a  foreign  body  is  present,  its  immediate  removal 
is  preferable  to  delay. 

(6)  A  case  is  seen  with  a  septic  wound. — If  the 
infection  is  confined  to  the  shaft,  sub-periosteal 
esquillectomy  through  a  posterior  incision  is  sufficient. 

If,  on  the  contrary,  the  fracture  implicates  the 
epiphyseal  ends  at  all,  or  if  there  is  the  slightest  sign 
of  involvement- of  the  joint,  sub-periosteal  resection, 
extensive  as  far  as  the  bones  of  the  forearm  are  con- 
cerned, but  limited  in  the  case  of  the  humerus,  should 
be  performed  at  once. 

(c)  A  C2se  is  seen  with  a  sinus. — ^After  X-ray  ex- 
amination, and  according  to  the  nature  of  the  lesion, 
the  following  steps  should  be  taken  : 


446  TREATMENT    OF    FRACTURES 

Removal  of  a  sequestrum  or  splinter,  if  the  bony 
lesion  is  limited. 

Resection,  if  injury  to  the  shaft  is  not  extensive, 
and  if  the  joint  is  clinically  involved. 

{d)  A  case  is  seen  with  a  pseudarthrosis  of  the  radius. 
— It  will  be  sufficient,  as  a  rule,  to  remove  the  upper 
fragment,  that  is,  the  head  of  the  radius  from  behind, 
to  obtain  great  functional  improvement,  provided 
that  the  fragment  does  not  include  much  of  the  shaft. 
It  is  necessary  for  pronation  and  supination  that  the 
radius  should  be  fixed  at  its  upper  extremity  ;  the 
annular  ligament  must,  in  fact,  support  all  or  part 
of  the  neck  of  the  radius. 

B.  Fractures  of  the  Shafts. 

1.  Anatomical  Features. — The  fragments  are 
usually  small,  and  not  markedly  displaced,  except  in 
bullet  wounds  showing  explosive  effects  ;  the  latter 
are  very  frequent,  and,  owing  to  their  variety,  are 
impossible  to  describe.  It  is  exceptional  to  see  the 
large-fragment  type,  but  the  cuneiform  fragment  is 
often  seen  in  both  bones  (fig.  75),  or  the  butterfly- 
wing  fracture. 

The  injuries  are  situated  at  the  same  level  in  the 
two  bones  or  at  different  levels,  according  to  the 
angle  of  incidence  of  the  projectile. 

An  important  fact  is  that  the  extent  of  the  fracture 
is  not  usually  the  same  in  the  two  bones. 

There  is,  as  a  rule,  little  longitudinal  displacement ; 
on  the  other  hand,  the  force  of  impact  almost  always 
causes  antero-posterior  displacement  with  postero- 
lateral angulation. 

According  to  its  situation,  the  fracture  is  either 
buried  beneath  the  flexor  muscles,  or,  on  the  other 
hand,  superficially  situated  in  the  tendinous  part  of 
the  forearm.     This  distinction  is  important. 

Associated  injury  to  neryes  is  frequent. 

2.  Physiological   Features. — These   are   of    the 


FRACTURES    OF    THE    FOREARM     147 

first  importance.  In  the  first  place,  the  fracture  de- 
stroys the  equilibrium  of  the  muscular  forces  of  prona- 
tion and  supination  :  nothing  can  prevent  the  upper 
fragment  from  being  completely  and  permanently 
supinated  by  the  contraction  of  the  biceps,  the 
supinator  par  excellence.  On  the  other  hand,  the 
lower  fragment    is    given    over   to    the    unrestricted 


Fig.  74. — Comminuted 
fracture. 


Fig.  75. — Cuneiform 
fractiire. 


pronating  forces  exerted  by  the  pronator  teres  and 
particularly  the  pronator  quadratus. 

The  two  fragments  consequently  rotate  on  their 
long  axes  in  opposite  directions  ;  in  the  words  of 
Destot,  "  Us  se  decalent  "  (disconnection,  or  counter- 
rotation,  occurs),  and  if  this  is  not  corrected,  if  the  two 
fragments  unite  in  the  position  imposed  by  the  an- 
tagonistic muscular  forces  acting  on  them,  the  bones 
unite,  with  the  muscles  completely  relaxed :  pro- 
nation and  supination  become  permanently  impossible. 

Moreover,  owing  to  the  momentum  of  the  missile, 
the  fragments  of  the  bones  are  frequently  displaced 


448  TREATMENT    OF    FRACTURES 

laterally.  If  the  displacement  occurs  inwards,  angula- 
tion is  produced  with  the  apex  to  the  inner  side  of  the 
forearm.  The  effect  of  this  is  to  abolish  the  external 
radial  curvature,  an  essential  factor,  as  we  have  seen, 
in  the  production  of  the  rotatory  movement  which  is 
the  basis  of  transition  from  pronation  to  supination. 

This,  therefore,  is  a  further  danger  which  threatens 
the  essential  function  of  the  forearm. 

The  other  lateral  displacements  are  less  serious,  but 
always  diminish  the  possible  range  of  pronation  and 
supination. 

Thert  are  further  physiological  aspects  to  be  con- 
sidered in  fractures  of  the  forearm,  which  will  be 
studied  in  connection  with  the  course  of  the  cases. 

3.  Course. — ^Apart  from  the  very  serious  fractures 
from  bullets  causing  explosive  effects  in  the  soft  parts, 
these  fractures  are  less  frequently  fatal  than  fractures 
of  the  shafts  of  other  bones.  Apart  from  cases  of  gas 
gangrene,  which  are  always  possible  if  early  disinfec- 
tion of  the  fracture  has  not  been  carried  out,  death 
does  not  result  from  fractures  of  the  radius  and  ulna  : 
the  bones  are  too  superficially  placed  and  too  accessible 
to  permit  the  development  of  the  most  serious  phe- 
nomena of  sepsis.  But  although  death  may  not  result 
from  a  fracture  of  the  forearm,  amputation  of  the 
arm  may  be  necessitated  by  a  fracture  of  this  kind, 
and,  above  all,  loss  of  use  of  the  hand  and  fingers  may 
very  easily  result  from  it. 

In  fact,  though  less  serious  than  elsewhere,  since 
the  formation  of  a  closed  cavity  is  less  likely  to  occur 
in  this  region,  the  development  of  septic  conditions 
is  equally  constant. 

Suppuration  causes  local  changes,  the  functional 
results  of  which  are  deplorable.  There  are  two  types, 
according  as  the  fracture  is  situated  in  the  muscular 
or  the  tendinous  part  of  the  forearm. 

(a)  In  Fractures  in  the  muscular  part  of  the  Fore 
arm. — Tracks  of  pus  separate  the  muscles,  insinuating 


FRACTURES    OF    THE    FOREARM      449 

themselves  between  them.  If  this  condition  is  treated 
by  repeated  and  prolonged  drainage,  damage  to  and 
loss  of  substance  of  the  flexor  muscles  result  from 
contact  with  pus  and  drainage  tubes,  and  even  from 
the  operations  required ;  these  lesions  ultimately 
result  in  sclerosed  muscles  and  contracting  scars. 

During  the  active  stage  of  infection  this  manifests 
itself  by  flexion  of  the  two  last  phalanges  upon  the 
palm  of  the  hand.  This  condition  is  very  painful, 
and  the  slightest  movement  of  the  fingers  causes  con- 
siderable suffering  ;  moreover,  unless  it  is  corrected 
at  an  early  stage,  muscular  scarring  will  render  it 
permanent  and  the  fingers  will  remain  flexed.  When 
this  contracture  is  studied,  it  will  be  seen  that  there 
is  no  possibility  of  straightening  the  fingers  while  the 
wrist  is  extended.  If,  on  the  other  hand,  flexion 
of  the  wrist  is  carried  out,  extension  of  the  fingers 
is  possible.  There  is  therefore  a  syndrome  of  cica- 
tricial shortening  of  the  flexors  identical  with  that 
caused  by  ischsemic  paralysis,  and  this,  being  caused 
by  a  loss  of  substance  and  cicatrisation,  is  a  permanent 
lesion.  It  can  only  be  remedied  by  shortening  the 
bones,  which  are  already  diminished  in  length  by  the 
fracture  ;  this  operation,  in  a  forearm  infected  for 
a  long  period,  is  done  under  very  unfavourable  con- 
ditions, and  its  functional  result  remains  doubtful. 

This  muscular  complication  in  high  fractures  of  the 
shafts  is  therefore  much  to  be  feared,  which  amounts 
to  saying  that  the  infection  causing  it  should  be 
anticipated. 

(6)  In  Fractures  in  the  tendinous  "part  of  the  Fore- 
arm.— The  infected  fractured  region  is  in  immediate 
contact  with  the  tendons  and  their  sheaths.  Further, 
it  frequently  happens  that  certain  tendons  have  been 
injured  directly  by  the  projectile  ;  they  are  severed 
or  lacerated,  but  repair  is  possible  if  the  injury  re- 
mains aseptic  ;  they  necrose~and  are  eliminated  if  it 
suppurates.     After  a  long  period  of  suppuration,  their 


450  TREATMENT    OF    FRACTURES 

ends  adhere  to  the  skin,  become  involved  in  a  block 
of  scar  tissue  in  such  a  way  that  when  anatomical 
cure  is  obtained,  functional  recovery  has  become 
impossible,  and  the  use  of  the  limb  is  permanently 
impaired. 

Wherever,  in  fact,  the  fracture  may  be  situated,  the 
consequences  of  infection  are  deplorable  from  the 
functional  point  of  view. 

This,  however,  is  not  all  that  may  supervene  in 
fractures  as  a  result  of  infection  ;  sepsis  also  intro- 
duces a  danger  of  pseudarthrosis,  and  in  the  following 
way.  The  gap  between  the  fragments  is  usually  wider 
in  one  bone  than  in  the  other  ;  as  fragments  gradually 
undergo  necrosis  and  are  eliminated,  there  is  a  loss 
of  bone  substance  in  each  case,  but  this  gap  is  wider 
in  one  than  in  the  other  ;  hence  a  tendency  to  pseud- 
arthrosis of  one  bone. 

Add  to  this  the  serious  disturbance  caused  by 
torsion  in  opposite  directions,  and  the  gravity  of  frac- 
tures of  the  forearm  from  the  functional  point  of  view 
will  be  understood. 

Everything  possible  should  therefore  be  done  to 
prevent  infection,  to  avoid  pseudarthrosis,  and  to 
reduce  the  fracture  suitably. 

4.  Indications  for  early  Treatment. — The  first 
necessity  in  this  case  as  in  all  others  is  completely  to 
prevent  the  development  of  septic  conditions  by 
thorough  exposure  of  the  affected  region  ;  permanent 
asepsis  assured  in  this  way  will  facilitate  reduction 
and  its  maintenance. 

It  is  further  necessary  to  reduce  the  gaps  between 
the  fragments  to  the  same  dimensions  in  order  to 
facilitate  union,  to  correct  torsion,  to  reduce  lateral 
displacements,  to  keep  lesions  of  the  flexors  under 
observation,  and  to  repair  injuries  to  tendons. 

Complete  recovery  of  the  functions  of  the  hand,  to 
which  treatment  is  mainly  directed,  is  therefore  a  very 
difficult  matter. 


FRACTURES    OF    THE    FOREARM     451 

Emphasis  is  again  laid  on  the  fact  that  asepsis  of 
the  fracture  is  an  essential  condition. 

For  this  reason  complete  sub-periosteal  esquillec- 
tomy  should  be  performed  after  an  X-ray  examina- 
tion as  early  as  possible. 

I  am  aware  that  some  surgeons  regard  it  as  useless 
because  grave  sepsis  is  uncommon,  but  I  consider  this 
argument  worthless.  The  object  of  intervention  is  to 
ensure  in  all  cases  as  complete  a  preservation  as  possible 
of  the  movements  of  the  hand,  and  of  pronation  and 
supination.  This  object  is  worthy  of  considerable 
effort,  and  systematic  intervention  is  the  only  means 
of  attaining  it.  There  is  no  other  way  of  ar  ling 
that  fistulous  callus-formation,  which  is  some  limes 
obtained  with  difficulty  after  several  months,  leaving 
the  forearm  thin,  scarred,  and  deformed,  the  hand  flat, 
its  muscles  degenerated,  and  the  fingers  shrunken,  weak, 
and  clumsy. 

5.  Technique. — Esquillectomy  is  carried  out,  when 
choice  is  possible,  by  means  of  a  median  posterior 
incision  if  the  fracture  is  situated  high  up  ;  this  in- 
cision should  pass  slightly  outwards  from  the  ulnar 
crest,  and  will  often  be  sufficient.  This  will  avoid  the 
necessity  of  making  a  second  incision  over  the  radius, 
which  would  risk  severance  of  the  motor  branches  to 
the  extensors. 

In  the  middle  of  the  forearm  it  is  preferable  to 
make  two  lateral  incisions,  each  over  the  projecting 
part  of  the  bone  to  be  exposed. 

As  the  fragments  are  usually  small  and  not  much 
displaced,  some  determination  is  necessary  to  perform 
adequate  esquillectomy,  that  is  to  say,  to  remove  each 
splinter  by  careful  use  of  the  rugine.  The  necessity 
of  ^avoiding  injury  to  the  periosteum  need  scarcely 
be  emphasised.  Care  must  be  taken  to  free  the  muscles 
from  minute  splinters  which  may  be  adherent  to 
them.  This  practice  will  obviate  a  great  deal  of 
abscess  formation  in  the  later  stages. 


452 


TREATMENT   OF   FRACTURES 


After  clearance  of  both  fractures,  the  width  of  the 
interfragmentary  gaps  should  be  compared,  and  these 
should  be  reduced  to  the  same  dimensions  :  the  best 
instrument  for  this  purpose  is  a  Gigli  saw.  Precautions, 
however,  should  be  taken  to  protect  the  periosteum. 


Fig    76. 


Fig.  77. 


Fig.  78. 


Fig.  76. — ^Radiograph  after  complete  esquillectomy  for  fracture  of 
both  bones  of  the  forearm  by  a  rifle  bullet  with  great  explosive 
effects.  The  operation,  performed  on  the  fourth  day,  obviated  the 
necessity  of  amputation  in  a  case  seriously  affected  by  infection, 
due  to  multiple  wounds,  including  a  fracture  of  the  tarsus. 

Fig.  77. — ^Two  months  later.  Approximation  of  the  fragments. 
The  two  extremities  of  the  radius  are  in  process  of  periosteal 
fusion  ;  the  fragments  of  the  ulna  are  less  widely  separated  than 
before,  and  the  neighbouring  periosteum  is  very  active. 

Fig.  78. — ^Two  months  later.  Union  is  complete  in  the  radius 
without  a  sinus.  The  ulna  has  not  reunited,  but  this  pseudarthro- 
sis  gives  little  trouble.  The  fingers  are  stiff,  but  no  tendons  have 
been  destroyed.  Resection  of  the  radius,  by  equalising  the  inter- 
fragmentary gaps,  would  probably  have  effected  union  of  both  bones. 

since  it  may  otherwise  be  lacerated  by  the  saw,  and 
periosteal  regeneration  thereby  jeopardised.  After 
the  operation,  a  dressing  of  aseptic  gauze  is  applied  to 
each  wound.     The  forearm  is  immobilised  in  a  position 


FRACTURES    OF    THE    FOREARM      453 


of  supination  and  semi-flexion.  The  best  means  of 
effecting  this  is  a  posterior  plaster  trough,  with  an 
aperture  for  the  thumb,  and  enclosing  the  palm  of  the 
hand  (fig.  87,  p.  471). 

If  esquillectomy  has  been  performed  correctly,  no 
difficulty  will  be  experienced  in  reducing  the  fracture 

and  maintaining  re- 
duction ;  for  this 
reason,  I  consider 
continuous  extension 
unnecessary. 

After  some  days, 
when  the  wounds  are 
healing  normally,  an 


Fig.  79. — Interrupted  plaster  splint  for  fracture  of  both 
bones  during  consolidation. 

interrupted  plaster  splint  may  be  subtetituted  to 
facilitate  dressing,  but  it  is  better  not  to  apply  this 
early,  unless  the  condition  of  the  wound  requires  it. 

This  plaster  includes  : 

{a)  An  upper  section,  enclosing  the  lower  part  of 
the  arm,  the  elbow,  and  the  upper  part  of  the  forearm  ; 

(6)  A  lower  section,  enclosing  the  lower  part  of  the 
forearm  and  the  hand  ; 

(c)  A  loop,  or  two  loops,  which  should  not  consist 
of  metal.  I  now  invariably  make  them  with  a  few 
layers  of  plaster  bandage,  held  in  position  by  an 
assistant  until  they  have  set ;  around  them  a  few 
more  turns  of  plaster  bandage  are  wound  for  the  sake 
of  strength  and  compactness. 

If  extension  should  appear  necessary,  it  should  be 


454 


TREATMENT   OF    FRACTURES 


effected  by  fitting  a  slide  or  screw  connection  to  the 
plaster,  such  as  is  illustrated  on  p.  375  No  appliances 
are  more  easily  constructed  than  these. 

Sometimes  it  will  be  well,  when  the  fracture  is  exactly 
in  the  middle  of  the  forearm,  to  support  the  dorsal 
aspect  by  means  of  a  plaster  rest  1  inch  in  width,  con- 
necting the   two    circular 
sections.    The  tendency  to 
posterior  sagging   of    the 
four  fragments  concerned 
may   be  avoided  in    this 
way. 

In  certain  cases,  con- 
tinuous extension  by  a  sus- 
pension apparatus  may  be 
employed  with  advantage. 
The  sling  should  consist  of 
strips  fixed  on  a  metal 
frame,  as  shown  in  fig.  80. 
Extension  is  applied  to  the 


Fig.  80. — Immobilisation  and  continuous  extension  in  a  suspen- 
sion apparatus.  Extension  by  a  weight  of  800  grammes,  counter- 
extension  800  grammes,  counterpoising  weight  1,200  grammes. 
For  the  sake  of  clearness,  the  hand  is  shown  in  semi-pronation,  and 
not  in  supination. 

lower  third  of  the  forearm.     Counter-extension  may, 
but  need   not   necessarily,  be  applied  to   the   elbow. 


FRACTURES    OF    THE    FOREARM       455 

A  simple  bracket  fitted  with  two  pulleys  is  used  to 
suspend  the  sling.     This  is  an  excellent  appliance. 

As  a  rule,  when  esquillectomy  has  been  performed 
promptly,  these  fractures  get  well  without  difficulty 
in  forty  or  fifty  days,  leaving  scarcely  any  trace  of  the 
injury,  unless  there  has  been  irreparable  damage  to 
muscle. 

In  addition  to  the  simple  cases  which  have  been 
studied  there  are  other  more  complicated  ones  : 

Apart  from  associated  nervous  lesions,  which  should 
be  treated  at  once  whenever  intervention  is  undertaken 
at  a  really  early  stage,  any  of  the  following  complica- 
tions already  alluded  to  may  occur,  according  to  the 
position  of  the  fracture  : 

(a)  In  fractures  high  up,  painful  contracture  of  the 
fingers,  due  to  irritation  of  the  flexors.  This  usually 
appears  at  a  later  stage,  and  does  not  occur  if  the  wound 
remains  aseptic. 

When  it  does  occur,  and  the  existence  of  true  con- 
tracture of  the  fingers  is  established,  the  wound  is 
first  examined,  and  continuous  extension  is  applied  to 
the  fingers.  For  this  purpose,  a  rigid  prolongation, 
of  wood,  plaster,  or  metal,  should  be  fixed  to  the 
plaster,  fitted  with  a  pulley  over  which  passes  a  traction 
cord  pulling  on  an  india-rubber  loop  passed  round  the 
fingers.  This  has  always  enabled  me  to  effect  a  slow 
straightening  of  the  fingers  ;  the  method  is  less  painful, 
and  undoubtedly  more  effective,  than  sudden  straight- 
ening by  force,  which  causes  injury,  and  is  therefore 
dangerous. 

This  complication  requires  early  treatment  and 
careful  attention,  for  the  contracture  gradually  be- 
comes more  marked,  straightening  becomes  more  and 
more  difficult,  and  ultimately  correction  by  operation 
is  necessary,  the  result  of  which  is  always  doubtful. 

(&)  In  wounds  in' the  lower  part  of  the  forearm,  in- 
volving tendons,  the  problem  presented  is  totally 
different. 


456  TREATMENT    OF    FRACTURES 

If  the  injury  to  tendons  is  not  extensive  and  is 
easy  to  repair,  and  if  the  wound  is  disinfected  at 
an  early  stage,  tendon  suture  should  be  performed  at 
once  with  all  the  care  which  this  delicate  operation 
requires. 

On  the  other  hand,  if  the  laceration  of  tendons  is 
very  extensive,  as,  for  instance,  in  bullet  wounds 
associated  with  explosive  effects,  and  if  there  is  no 
certainty  of  ultimately  producing  complete  asepsis  of 
the  wound,  it  is  better  to  postpone  tendon  suture  for 
the  time  being,  and  merely  as  far  as  possible  to  prevent 
complications  in  the  immediate  neighbourhood  of  the 
fracture.  There  should  even  be  no  hesitation  in 
excising  any  sections  of  tendon  which  are  completely 
destroyed  and  would  eventually  be  eliminated.  This 
is  a  matter  for  surgical  common  sense  which  cannot  be 
expressed  in  formulae. 

6.  Treatment  of  cases  seen  at  a  late  stage, 
OR  already  under  Treatment. — (a)  A  case  'pro- 
gressing well  without  operation. — If  there  is  no  pyrexia 
and  no  suppuration,  intervention  is  obviously  not 
called  for,  and  all  that  is  necessary  is  fixation  in 
good  position  (supination,  with  the  hand  flat),  but 
continuous  extension  should  be  combined  with  this, 
and  in  such  a  case  the  looped  plaster  appliance 
should  be  replaced  by  one  with  sliding  shafts, 
or  with  concentric  cylinders  kept  apart  by  a  spring. 
This  fixation  with  extension  should  be  continued  for 
thirty  to  forty  days.  At  the  end  of  this  time,  it  should 
be  ascertained  clinically  and  by  X-rays  whether  union 
has  occurred.  If  the  bone  is  solid,  cautious  move- 
ments are  begun  ;  the  limb  is  placed  in  the  plaster  again 
at  certain  hours  and  during  the  night  for  about  twelve 
days.  If  the  callus  is  soft,  the  limb  should  be  care- 
fully re-immobilised,  since  otherwise  there  is  a  danger 
of  secondary  curvature. 

(&)  A  case  is  seen  in  a  septic-  condition. — The  region 
of  the  fracture  must  be  completely  cleaned  at  once  ; 


FRACTURES    OF    THE    FOREARM       457 

as  has  already  been  said,  sub-periosteal  esqiiillectomy 
of  both  bones  should  be  performed,  the  two  inter- 
fragmentary gaps  being  reduced  to  equal  dimensions. 
It  is  sometimes  of  advantage  to  smooth  off  the  ex- 
tremities with  a  saw,  or  at  least  to  abolish  marked 
irregularities,  but  in  doing  this,  particular  care  should 
be  taken  with  the  periosteum,  which  should  be  kept 
well  clear  of  the  saw. 

If  tracks  of  pus  are  present,  they  should  be  widely 
exposed  :  the  best  method  of  preserving  the  muscles 
is  to  protect  them  from  infection  and  from  prolonged 
contact  with  pus.  1  cannot  explain  the  lack  of 
biological  understanding  in  certain  surgeons  who  permit 
sclerosis  and  atrophy  of  .the  muscles  in  order  to  avoid 
a  cutaneous  scar.  It  should  therefore  be  remembered 
that  the  best  means  of  avoiding  extensive  scars  in 
these  dases  is  to  make  a  large  incision  in  good  time. 
If  gangrenous  fasciae  and  necrosing  tendons  are  exposed 
in  this  way,  everything  should  be  excised  which  is 
undergoing  necrosis  ;  it  is  no  economy  to  leave  in  a 
wound  tissues  which  must  ultimately  die. 

It  will  be  said  that  this  requires  experience,  and  this 
is  true,  as  it  is  true  of  all  surgery. 

When  the  bony  region  has  been  surgically  cleaned 
in  this  way,  and  the  tracks  of  pus  have  been  exposed, 
the  wound  should  merely  be  plugged  loosely  with 
aseptic  gauze,  and  the  limb  correctly  immobilised  while 
the  sepsis  diminishes.  Suppuration  quickly  ceases, 
and  the  subsequent  course  is  that  of  a  fracture  dis- 
infected at  an  early  stage.  Occasionally,  however, 
suppuration  reappears  to  some  extent  after  a  time, 
and  the  edges  of  the  wound  become  ODdematous,  but 
there  is  no  constitutional  disturbance.  This  is  due 
to  necrosis  of  a  ring-shaped  fragment  at  one  or  more 
of  the  bony  extremities  concerned ;  after  gentle 
removal  of  these  small  and  still  adherent  sequestra  by 
means  of  forceps,  suppuration  ceases,  and  union  is 
scarcely  delayed  by  it.     Union  never  fails  to  occur, 


458  TREATMENT    OF    FRACTURES 

and  speaking  personally,  I  have  never  yet  seen  a 
pseudatrthrosis  of  both  bones  of  the  forearm.* 

During  progress  towards  recovery,  inflammatory 
contraction  may  develop,  followed  by  cicatricial  con- 
traction of  the  flexors,  causing  the  syndrome  that  has 
already  been  discussed. 

This  singularly  troublesome  deformity  must  be 
watched  for  and  not  permitted  to  develop  or,  above 
all,  to  become  permanent. 

I  have  already  explained  how  it  could  be  corrected 
by  continuous  extension  of  the  fingers. 

In  the  event  of  grave  infection,  amputation  may  be- 
come necessary  ;  hitherto,  I  have  always  been  able 
to  avoid  it  by  free  esquillectomy. 

(c)  A  case  heals  with  marked  angulation  or  other 
vicious  union.- — If  union  is  recent,  it  is  generally 
possible,  under  an  anaesthetic,  to  rectify  the  position 
by  hand. 

On  the  other  hand,  if  the  callus  is  very  resistant,  the 
only  resource  is  osteotomy,  which  should  be  performed 
at  the  original  point  of  fracture. 

There  is  often  hesitation  in  performing  osteotomy, 
because  this  is  sometimes  followed  by  a  sudden  and 
dangerous  redevelopment  of  infection.  In  my  own 
experience,  there  is  nothing  more  easy  than  to  avoid 
such  bacterial  recrudescence  ;  it  is  merely  necessary 
to  leave  the  wound  open,  using  no  sutures,  and  plugging 
down  to  the  bone  surfaces. 

With  this  method  I  have  never  yet  seen  osteotomies 
followed  by  serious  infection. 

Fixation  of  the  hand  in  extreme  pronation  calls  for  the 
same  operation.     I  have  obtained  good  results  from  it. 

(d)  A  case  is  seen  with  radio-ulnar  synostosis. — This 
is  unusual  :    up  to  the  present  I  have  only  seen  very 

*  Since  writing  this  I  have  seen  pseudarthrosis  in  a  case  which 
suppurated  for  a  long  period  after  inadequate  esquillectomy  and 
the  elimination  of  several  sequestra.  Double  osteosynthesis  was 
necessary. 


FRACTURES    OF    THE    FOREARM      450 


high  radio-ulnar  synostosis  in  the  upper  third  of  the 
forearm,  the  connection  with  one  of  the  bones  being 
very  slight. 

If  the  position  is  bad,  as  is  usually  the  case,  the 
hand  being  fixed  in  extreme  prona- 
tion by  counter- torsion,  mere  de- 
struction of  the  synostosis  will  not 
restore  normal  movements.  More- 
over, it  is  a  difficult  operation,  par- 
ticularly in  the  upper  part  of  the 
forearm,  where  the  only  possible  ap- 
proach to  the  synostosis,  by  a  pos- 
terior incision,  is  complicated  by  the 
presence  of  the  motor  branches  of 
the  radial  nerve. 

The  bone  connection  is  always 
found  to  be  much  larger  than  it 
appeared  in  the  radiograph. 

In  a  case  of  this  kind  I  have  had 
great  difficulty  in  attaining  the  de- 
sired result. 

I  therefore  believe  it  preferable 
merely  to  correct  the  deformity  by 
osteotomy  and  fixation  by  a  Lam- 
botte  plate  :  I  have  obtained  a  very 
satisfactory  result  in  this  way. 

(e)  A  case  is  seen  with  a  pseudar- 
throsis. — This  again  is  an  unusual 
occurrence  ;  pseudarthrosis  of  both 
bones  of  the  forearm  is  fortunately 
very  exceptional,  as  this  is  a  very 
troublesome  condition.  I  have  never 
seen  it,  and  Nove-Josserand  recently 
said  that  he  had  never  operated  on 
such  a  case.  This  is  explained  by  the  fact  that  pseud- 
arthrosis is  due  to  the  impossibility  of  reducing  the 
interfragmentary  gap  owing  'to  the  presence  of  the 
other  bone  in  a  healthy  and  therefore  rigid  condition. 


Fig.  81.— Radio- 
ulnar synostosis. 
The  ulnar  lesion 
is  inconsiderable, 
but  the  connection 
is  twice  as  exten- 
sive as  the  radio- 
graph indicates. 
This  was  broken 
down.  It  would 
have  been  simpler 
to  perform  oste- 
otomy below  the 
callus,  and  this 
would  have  given 
an  equally  good 
result. 


460 


TREATMENT    OF    FRACTURES 


Should  it  occur,  the  solution  of  the  difficulty  is  double 
metal  fixation,  after  suitable  trimming ;  a  double 
bone-graft  is  a  very  doubtful  proceeding.  The  use 
of  an  external  support  slightly  reduces  the  serious 
functional  disorders  caused  by  pseudarthroses,  but  it 
is  only  a  makeshift. 

C.  Fractures  lust  above  the  Wrist. 

1.  Anatomical  Features. — These  fractures  are 
exceptional,  as  only  one  epiphysis  is  usually  injured. 
They  are  characterised  by  com- 
minution of  the  lower  epiphyseal 
ends  of  the  radius  and  ulna.  Fis- 
sures pass  upwards  into  the  shaft, 
but  in  my  experience  the  cartilage 
of  the  wrist- joint  is  usually  intact 
and  fissures  into  the  joint  do  not 
occur. 

The  injury  is  always  more  ex- 
tensive in  one  bone  than  in  the 
other  ;  the  radius,  being  more  ex- 
posed, is  almost  always  the  more 
seriously  injured. 

The  frequent  association  of 
serious  tendon  and  nerve  lesions 
should  be  noted. 

2.  Physiological  Features. — 
There  are  few  of  importance,  at 
least  in  the  early  stages :  scarcely 
any  displacement  occurs,  because 
there  is  little  muscular  action  to 
effect  it ;  counter-torsion  due  to 
the  action  of  the  pronator  quadratus  is  possible,  but 
is  not  constant. 

From  a  general  point  of  view,  there  is  a  prospect  of 
serious  interference  with  function  (loss  of  pronation 
and  supination,  associated  injuries  to  the  median  and 
ulnar  nerves,  and  to  tendons). 


Fig.  82. — Epiphy- 
seal radio-ulnar  sy- 
nostosis with  pseud- 
arthrosis  of  the 
radius,  following 
extra-periosteal  es- 
quillectomy.  Power 
of  pronation  and 
supination  is  lost, 
but  the  hand  is  well- 
and  rigidly  sup- 
ported. 


FRACTURES    OF    THE    FOREARM       4^1 

3.  Course. — This  fracture  is  extremely  serious, 
unless  immediate  disinfection  is  practised.  Infection 
develops  readily  in  the  cancellous  tissue  of  the 
epiphyses,  sometimes  spreads  to  the  carpus  (even  when 
fissures  are  not  present),  but  in  particular  almost  in- 
variably extends  along  the  tendons  and  their  sheaths 
hence  the  phlegmanous  suppuration  which  is  only  to 
often  followed  by  amputation. 

In  those  exceptional  cases  which  progress  well  with- 
out esquillectomy,  the  orthopaedic  and  functional  result 
is  generally  deplorable  ;  the  hand,  through  want  of 
attention,  becomes  fixed  in  a  vicious  position  (extreme 
pronation)  ;  further,  owing  to  the  unequal  size  of  the 
two  interfragmentary  gaps,  lateral  deviation  of  the 
hand  is  produced,  the  latter  being  forced  over  on 
the  side  of  the  shorter  bone  by  the  longer.  These  are 
incurable  deformities,  of  which  lamentable  examples 
may  be  seen  in  the  Physiotherapy  departments  at  the 
base. 

I  have  never  seen  pseudarthrosis  of  both  bones,  but 
I  have  met  with  a  curious  case  of  radial  pseudarthrosis 
compensated  by  radio-ulnar  synostosis  (fig.  82). 

4.  Indications  for  early  Treatment. — There  is 
only  one :  double  sub-periosteal  esquillectomy  must 
be  performed  as  quickly  as  possible,  the  two  inter- 
fragmentary gaps  being  reduced  to  roughly  the  same 
dimensions,  unless  the  loss  of  bone  is  more  extensive 
in  the  ulna.  Pseudarthrosis  of  the  ulna  low  down 
interferes  so  little  with  function  that  it  is  practically 
negligible  ;  it  is  therefore  sufficient  to  ensure  union  of 
the  radius. 

Sometimes  the  clearance  will  end  by  leaving  only  a 
thin  layer  of  cancellous  tissue  on  the  upper  surface  of 
the  radio-carpal  cartilage.  This  need  cause  no  alarm  ; 
if  no  fissures  are  present,  and,  in  particular,  no  infection, 
an  uneventful  recovery  will  follow,  without  reaction 
on  the  joint 

In  operating  on  the  radius,   the  medullary  canal 


462 


TREATMENT    OF    FRACTURES 


should  be  examined  carefully  in  all  cases  ;  on  several 
occasions  I  have  found  fragments  of  the  coat-sleeve 
firmly  ground  into  the  bone  that  could  not  be  detached 
without  energetic  curetting.  I  need  not  insist  on  the 
disadvantages  of  leaving  such  structures  in  the  bone. 
Technique. — The   esquillectomy  is  effected  through 

two  lateral  incisions, 
situated,  if  possible, 
on  the  dorsal  aspect. 
In  the  case  of  the 
radius,  this  possesses 
the  advantage  of 
avoiding  the  radial 
artery,  and  further,  it 
is  easier  to  preserve 
intact  the  external 
column  of  the  styloid 
process,  which  is  fre- 
quently uninjured. 
Lastly,  it  allows  of 
more  convenient  fixa- 
tion. 

After  an  aseptic 
dressing  has  been  put 
on,  fixation  is  effected 
by  a  palmar  support, 
similar  to  that  used 
after  resection  of  the 
wrist.  It  should  per- 
mit the  wound  to  be 
attended  to  without 
the  limb  being  removed  from  the  plaster. 

Assuming  the  almost  certain  loss  of  pronation  and 
supination,  the  limb  should  be  immobilised,  if  not  at 
once,  certainly  later,  in  a  position  of  semi-pronation 
with  the  thumb  vertical. 

As  a  rule  the  subsequent  course  of  the  injury  is 
uneventful,  and  healing  occurs  without  suppuration. 


Fig.  83. — Fixation  in  a  position  of 
semi-pronation  by  means  of  a  plaster 
trough. 


FRACTURES    OF    THE    FOREARM       403 


If  this  is  the  case,  it  is  decidedly  advisable  to  perform 
any  necessary  tendon  or  nerve  suture  at  an  early  stage. 
The  wound  is,  as  usual,  packed  with  gauze,  and  as  a 
rule  the  result  obtained  is  surprisingly  excellent. 

In  my  experience,  union  occurs  in  about  fifty  to  sixty 
days. 

5.  Treatment  of  cases  seen  at  a  later  stage, 
or  already  under  treat- 
MENT.— (a)  A  case  progressing 
well. — No  operation  should  be 
attempted,  but  strict  immo- 
bilisation, with  the  thumb 
vertical,  is  required.  After 
X-ray  examination,  dead 
splinters  and  foreign  bodies, 
if  any  are  present,  should  be 
removed. 

(b)  A  case  arrives  in  a  septic 
condition.— The  temperature 
is  high  and  the  forearm  and 
wrist  are  red  and  swollen. 
The  exact  topography  of  the 
injury  is  determined  from  a 
radiograph,  very  careful  total 
esquillectomy  is  performed, 
and  the  medullary  canal  and 
the  cancellous  tissue  of  the 
epiphysis,  particularly  that  of 
the  radius,  are  cleaned  with 
a  curette. 

Tracks  of  pus,  if  any  are 
present    in    the    region,     are 

laid  widely  open,  and  all  necrosing  tissue  is  excised. 
Tendon  suture  should  not  be  attempted  at  this  stage, 
the  only  object  of  the  operation  being  to  save  the  hand, 
even  at  the  expense  of  ultimately  sacrificing  fingers 
which,  owing  to  irreparable  injury  to  their  tendons, 
will  henceforth  be  a  useless  hindrance. 


FiG^.  84. — Explosive  ef- 
fects from  a  rifle  discharged 
in  the  near  vicinity  of  the 
forearm ;  wound  seriously 
infected  ;  total  sub-perios- 
teal  esquillectomy  on  the 
third  day  obviated  the  ap- 
parent necessity  of  an  am- 
putation. 


464 


TREATMENT    OF    FRACTURES 


In  this  way  amputation  can  be  avoided  even  in  the 
worst  cases,  and  a  hand  preserved  with  some  at  least 
of  its  fingers  useful.  Esquillectomy,  in  fact,  with 
excision  of  necrosed  tissues  rapidly  arrests  infection, 
and  thus  preserves  tendons  which  would  be  destroyed 
by   prolonged   suppuration.     An   extensive   operation 


Fig.  85. — Anatomical  result  three  months  later  of  esquillectomy 
(see  fig.  84)  :  solid  callus  without  osteitis ;  healing  complete  a 
month  previously.  Flexion  and  extension  of  the  wrist  normal, 
supination  very  limited.  Finger  movements  almost  normal,  except 
in  the  last  two,  in  which  flexion  is  poor. 

is  the  only  truly  conservative  method,  and  I  cannot 
too  strongly  recommend  it. 

During  the  first  few  days  fixation  is  effected  merely 
by  means  of  an  iron  wire  splint,  the  wound  being 
dressed  daily  until  a  marked  reduction  in  the  sepsis 
occurs.     When  suppuration  is  totally  arrested  and  the 


FRACTURES   OF    THE    FOREARM      465 

appearance  of  the  wound  is  favourable,  which  will 
usually  be  the  case  in  eight  to  ten  days,  less  frequent 
dressing  is  necessary.  At  this  stage  it  is  best  to  make 
a  posterior  plaster  trough  enclosing  the  palm  and 
passing  round  the  base  of  the  thumb.  The  hand  is 
immobilised  in  semi-pronation,  the  thumb  directed 
upwards,  and  the  elbow  flexed  to  a  right  angle  (fig.  83). 

The  plaster  extends  upwards  as  far  as  the  middle 
part  of  the  arm,  and  not  farther  downwards  than  the 
lower  palmar  fold,  in  order  to  allow  of  flexion  of  the 
fingers. 

The  plaster  is  removed  for  each  dressing,  that  is, 
every  seven  or  eight  days,  which  is  very  soon  possible 
when  the  operative  disinfection  has  been  well  carried 
out. 

Union  usually  occurs  in  two  to  three  months. 

If  esquillectomy  should  fail  and  grave  sepsis  develop, 
amputation  is  unavoidable,  but  I  have  always  found 
the  former  operation  sufficient. 

II.  FRACTURES    OF    THE   RADIUS  ALONE 

Two  varieties  are  to  be  distinguished  : 
Fracture  of  the  shaft  proper. 
Fracture  of  the  lower  epiphysis. 

A.  Fracture  of  the  Shaft. 

1.  Anatomical  Features. — The  fracture  is  usually 
comminuted,  but  obviously  all  varieties  are  possible. 
As  a  rule,  there  are  no  radiating  fissures. 

Serious  injury  to  tendons  is  almost  always  associated 
with  this  fracture.  The  extensors  are  more  or  less 
destroyed.  In  fractures  of  the  distal  part  of  the 
shaft,  all  the  dorsal  tendons  of  the  thumb  (the  long 
abductor,  the  short  extensor,  and  the  long  extensor) 
and  the  two  radialis  tendons  are  frequently  severed  ; 
injuries  to  the  radial  artery  and  the  superficial  branch 
of  the  radial  nerve  are  equally  frequent. 


466  TREATMENT    OF    FRACTURES 

2.  Physiological  Features. — The  upper  fragment 
usually  remains  in  position  ;  it  is  only  displaced  in 
fractures  of  the  upper  end  of  the  shaft,  when  the 
biceps  pulls  it  forward  [i.e.  flexes  it). 

On  the  other  hand,  in  all  cases,  whatever  the  position 
of   the  fracture,   the   supinating   action   of  the   same 
muscle  comes  into  play,  and,  reinforced  by  that  of- 
the  supinator  brevis,  supinates  the  upper  fragment. 

The  lower  fragment  invariably  undergoes  inward 
displacement  towards  the  interosseous  space,  owing 
to  the  action  of  the  pronators.  In  fractures  of  the 
middle  of  the  shaft  it  almost  always  comes  into  contact 
with  the  ulna.  Hence  there  is  lateral  displacement,  in 
the  form  of  angulation,  opening  outwards.  Similarly, 
the  same  muscles  induce  more  or  less  marked  pronation, 
and  complete  counter-torsion  by  rotating  the  lower 
fragment  on  its  own  axis,  in  a  direction  opposite  to 
that  of  the  upper  fragment. 

The  final  result  is  that  the  fragments  correspond 
neither  anatomically  nor  physiologically,  which  inter- 
feres with  union  and  destroys  the  essential  function  of 
the  forearm. 

3.  Course. — Fracture  of  the  shaft  of  the  radius, 
unless  caused  by  a  short-range  bullet,  and  therefore 
marked  by  very  extensive  injury  to  muscle  and 
tendons,  is  very  unlikely  to  prove  fatal.  The  situation 
of  the  bone  being  superficial,  fractures  due  to  shell- 
fragments  may  not  give  rise  to  any  immediate  and 
serious  septic  phenomena.  The  fact  remains,  however, 
that  infection  is  practically  constant,  and  will  at  least 
cause  necrosis  of  splinters,  which  are  gradually  elimi- 
nated and  destroy  bone-forming  tissue.  This  explains 
the  frequent  occurrence  of  spontaneous  pseudarthrosis, 
apart,  of  course,  from  pseudarthrosis  due  to  badly 
performed  esquillectomy. 

Further,  the  functional  significance  of  tendinous 
lesions  increases  if  the  wound  suppurates  ;  an  injury 
to   a   tendon    that   could    be    repaired    after   aseptic 


FRACTURES   OF    THE    FOREARM     467 

healing  of  the  wound  becomes  incurable  when  in- 
fection causing  necrosis  of  the  fragile  extremities  finally 
destroys  a  considerable  proportion  of  the  length  of 
the  tendon. 

Lastly,  a  fracture  which  originally  seemed  quite 
mild  may  become  a  very  serious  affair  if  prolonged 
suppuration  causes  extensive  muscular  sclerosis. 

The  functional  prognosis  therefore  depends  on  early 
disinfection  of  the  fracture  ;  it  is;  in  fact,  essential  to 
the  future  safety  of  the  hand  that  these  fractures 
should  not  suppurate.  Asepsis  is  a  necessity  from 
another  point  of  view  :  the  complex  arrangement  of 
muscular  origins  in  the  forearm  necessitates  perfect 
reduction  and  strict  subsequent  fixation,  and  to  induce 
and  maintain  these  conditions  satisfactorily  in  spite 
of  prolonged  suppuration  is  a  difficult  matter. 

If  none  of  this  is  effected,  fracture  of  the  shaft  of 
the  radius  is  equivalent  to  mutilation  :  the  forearm 
becomes  fixed  in  extreme  pronation,  with  marked 
radio-ulnar  dislocation ;  the  muscles  and  tendons 
destroyed  are  definitely  and  permanently  lost,  and 
the  hand  is  an  impotent,  clumsy,  useless,  and  painful 
appendage. 

But  this  is  not  all  :  the  contraction  of  the  infected 
soft  parts  in  the  neighbourhood  of  the  fracture,  the 
natural  tendency  of  the  muscles  to  pull  the  lower 
fragment  upwards  and  inwards,  and  the  loss  of  bone 
caused  by  the  elimination  of  splinters  and  destruc- 
tion of  their  periosteum,  diminish  the  length  of  the 
radius,  and  accentuate  its  original  deviation  deformity. 
The  callus  perpetuates  this  vicious  position,  and  the 
two  bones  of  the  forearm  are  no  longer  in  harmony  ; 
the  ulna  tends  to  adapt  itself  to  the  dimensions  of  the 
radius  by  bending  and  causing  a  curved  projection  on 
the  internal  surface  of  the  forearm,  but  this  is  insuffi- 
cient to  compensate  for  the  diminution  in  length  of 
the  bone  with  which  it  is  connected  ;  its  styloid  process 
appears  to  be  displaced  from  the  carpus  and  encroaches 


408  TREATMENT    OF    FRACTURES 

on  the  base  of  the  hand,  which  it  appears  to  be  forcing 
outwards.  This,  however,  is  only  an  appearance.  In 
reality  the  hand  follows  the  radius,  to  which  it  is  more 
closely  attached,  outwards  with  the  lower  fragment 
of  that  bone.  This  displacement  is  due  to  the  upward 
and  inward  movement  of  this  part  of  the  shaft,  and 
in  this  way  very  troublesome  radial  deflection  of  the 
hand  is  produced.  In  itself,  and  altogether  apart 
from  any  musculo-tendinous  lesion,  or  counter-torsion, 
this  deformity  interferes  considerably  with  the  move- 
ments of  pronation  and  supination. 

Nor  should  it  be  regarded  as  a  rare  occurrence.  In 
different  degrees  it  is  very  frequent,  and  this  frequency 
necessitates  certain  treatment  which  will  be  discussed 
later. 

In  short,  fracture  of  the  shaft  of  the  radius,  if  infected 
or  badly  reduced,  is  liable  to  cause  pseudarthrosis, 
damage  to  tendons,  loss  of  pronation  and  supination, 
and  outward  deviation  of  the  hand. 

It  is  therefore  not  a  fracture  which  can  be  regarded 
as  a  mild  lesion. 

4.  Indications  for  early  Treatment. — As  has 
been  said,  every  effort  should  be  made : 

(a)  To  prevent  suppuration  ; 

(6)  To  induce  and  maintain  reduction  ; 

(c)  To  ensure  that,  after  union,  the  shaft  of  the  radius 
will  be  equal  in  length  to  that  of  the  ulna. 

This  may  be  effected  in  the  following  way  : 

(i)  Asepsis  is  assured  by  early  sub-periosteal  esquil- 
lectomy  ; 

(ii)  Reduction  by  immobilising  in  the  position  of  full 
supination  ; 

(iii)  Restoration  of  equality  in  length  of  the  two  bones 
by  secondary  resection  of  a  small  piece  of  the  ulna,  if  the 
interfragmentary  gap  in  the  radius  is  rather  wide. 

It  may  be  thought  that  the  third  clause  of  the  treat- 
ment is  necessitated  by  the  first,  which  causes  a  loss 
of  bone-substance,  and  it  will  perhaps  be  said  that  if 


FRACTURES    OF    THE    FOREARM      460 


adherent  splinters  w 
were  therefore  not 
diminished  in 
length,  resection  of 
the  ulna  would  be 
unnecessary.  But 
the  objection  is 
scarcely  worthy  of 
attention  :  the 
s  t  u  dy  of  en  d- 
results,  such  as  is 
possible  at  medical 
boards  and  ortho- 
paedic c  o  n  s  u  1 1  a- 
tions,  shows  that 
radial  deflection  of 
the  hand  occurs 
very  frequently  in 
cases  which  have 
suppurated  for  long 
periods  without 
having  had  an  es- 
quillectomy  done, 
and  in  which, 
therefore,  an  inter- 
fragmentary peri- 
osteal callus  should 
consequently  have 
been  most  easily 
able  to  form.  In 
actual  fact,  the 
best  method  of  pre- 
venting diminution 
in  length  of  a  frac- 
tured bone  is  to 
facilitate  osseous 
proliferation  within 
performing  a  correct 


ere  not   removed  and  the  radius 


FiQ.  80. — Fracture  of  the  shaft  of  the 
radius  by  a  shell-fragment,  treated  at  the 
front  by  simple  transosseous  di'ainage. 
Serious  infection  ;  case  complicated  by 
fracture  of  the  humerus.  These  two 
fractiu-es  were  treated  on  the  thiid  day 
by  total  sub-periosteal  esquillectomy. 
After  six  weeks  union  had  occurred  in 
the  humerus,  but  not  in  the  radius  ;  ten- 
dency in  the  hand  to  outward  deviation. 
I  resected  \  inch  of  the  ulna  without 
interfering  with  the  radius.  Fixation  by 
plaster  (corrective)  was  followed  by  rapid 
union.  Complete  cure  in  tlu-ee  months, 
with  all  movements  preserved. 

the  cylinder   of   periosteum,    by 
esquillectomy. 


470  TREATMENT    OF    FRACTURES 

After  clearance,  resection  of  the  ulna  is  advisable 
if  the  interfragmentary  radial  gap  exceeds  an  inch 
in  length,  not  so  much  to  avoid  pseudarthrosis,  which 
is  unlikely  to  occur,  as  to  ensure  perfect  harmony 
between  the  two  associated  bones.  The  physiology 
of  the  question  shows  that  the  radius  and  ulna  being 
connected  as  they  are,  the  slightest  diminution  in 
length  of  one  of  them  causes  dislocation  of  one  of  their 
joints,  and  consequent  serious  disorder  of  function.  I 
have  practised  this  resection  of  the  ulna  for  several 
months  past,  and  during  that  period  have  noticed  a 
considerable  improvement  in  functional  recovery  in 
the  patients  concerned. 

5.  Technique. — Esquillectomy  is  effected  by  means 
of  an  external  lateral  incision,  widely  exposing  the  area 
of  bone  injury.  The  clearance  should  be  strictly 
sub-periosteal,  and  in  almost  all  cases,  total ;  careful 
attention  to  detail  is  required.  The  flexors  should 
not  be  disturbed  from  beneath,  and  as  far  as  possible 
the  wound  should  not  be  plugged  from  the  internal 
side. 

Reduction  is  easily  effected  by  immobilising  the  elbow, 
forearm,  and  hand  in  a  posterior  plaster  trough,  the 
position  being  one  of  full  supingttion,  the  palm  of 
the  hand  being  horizontal  and  facing  upwards,  and  the 
hand  inclined  strongly  towards  the  ulnar  side.  This 
plaster  is  retained  or  renewed  until  union  has  begun, 
which  should  occur  in  about  eight  weeks. 

After  four  or  five  weeks,  and  after  examination  of 
radiographs  taken  from  each  aspect,  the  plaster  is 
removed  for  investigation  of  the  callus.  If  the  inter- 
fragmentary space  is  rather  wide  (more  than  1  inch), 
and  particularly  if  the  ulna  is  jirojecting  a  little  on 
the  internal  aspect  of  the  forearm,  about  1  inch  of  the 
ulna  should  be  resected.  The  best  moment  for  this  is 
the  stage  at  which  the  callus,  though  still  soft,  is  clearly 
visible  in  the  radiograplis  as  a  darkish  shadow  in  and 
around  the  interfragmentary  space. 


FRACTURES    OF    THE    FOREARM      471 

This  resection,  which  should  be  strictly  sub-periosteal, 
is  conducted  in  the  following  way  :  a  point  should  be 
chosen  at  some  distance  from  the  fracture,  and  the 
lower  end  of  the  ulna  is  ideal  from  this  point  of  view. 
The  bone  is  isolated  with  the  rugine,  the  edge  of  which 
should  be  kept  in  close  contact  with  the  compact  bone, 
in  order  to  leave  as  much  periosteum  as  possible  in 


Fig.  87. — Fixation  in  a  plaster  splint  in  a  position  of  supination 
the  hand  inclined  to  its  ulnar  side,  after  secondary  resection  of  the 
ulna,  following  esquillectomy  for  fracture  of  the  radius, 

the  wound.  The  entire  circumference  of  the  bone 
being  well  exposed,  a  chain  or  Gigli  saw  is  passed 
round  it,  and  a  section  of  bone  about  1  inch  in 
length  is  excised.  There  need  be  no  fear  of  removing 
too  much  ;  in  practice  there  is  a  natural  tendency  to 
be  very  economical  and  to  remove  too  little.  It  is 
better,  when  possible,  to  fix  the  two  fragments  by  means 
of  a  metal  clip,  wire,  or  Lambotte  plate ;  I  have  often, 


47^  TREATMENT    OF    FRACTURES 

however,  dispensed  with  this.  The  wound  is  simply 
plugged  and  not  sutured  ;  the  piece  of  bone  removed 
from  the  ulna  may  be  placed  in  the  interfragmentary 
gap  of  the  radius  if  this  is  wide  enough.  It  is  of 
advantage  to  re-expose  the  radial  region,  and  to 
irritate  it  a  little  with  the  curette  in  order  to 
stimulate  bone-formation.  The  forearm  is  then 
immobilised  in  supination  as  before,  with  the  hand 
deflected  towards  its  ulnar  side. 

After  this  operation,  the  rapidity  of  callus-forma- 
tion and  the  functional  perfection  attained  are  sur- 
prising. 

This  slight  interference,  in  fact,  absolutely  prevents 
pseudarthrosis  and  deviation  of  the  hand,  and  ensures 
maintenance  of  the  anatomical  conditions  necessary 
for  the  recovery  of  pronation  and  supination. 

6.  The  Treatment  of  cases  examined  at  a  late 

STAGE,    OR   ALREADY  UNDER    TREATMENT. (a)   A    CaSe 

arrives  after  two,  three,  or  four  days,  doing  well. — If 
there  is  no  trace  of  infection,  the  fracture  need  merely 
be  reduced  and  immobilised  in  supination  in  a  posterior 
plaster.  In  this  exceptional  case,  in  which  the  absence 
of  infection  abolishes  the  necessity  for  esquillectomy, 
all  efforts  should  be  directed  to  ensuring  functional 
recovery.  After  what  has  already  been  said,  it  is 
unnecessary  to  emphasise  the  importance  of  placing  the 
forearm  in  supination,  and  of  verifying  reduction  by 
a  radiograph.  If  signs  of  slight  infection  should  appear 
later,  and  splinters  are  eliminated,  it  should  be  decided 
by  clinical  and  radiographic  methods  whether  the  length 
of  the  ulna  should  be  reduced  as  a  precautionary 
measure,  since  otherwise  an  originally  benign  fracture 
might  finally  produce  deplorable  functional  effects. 

(6)  A  case  is  seen  in  a  septic  condition. — Sub- 
periosteal esquillectomy  and  drainage  should  be  per- 
formed at  once  ;  total  clearance  is  almost  always 
necessary,  and  particular  care  should  be  exercised  in 
separating  the  periosteum. 


FRACTURES    OF    THE    FOREARM       473 

Fixation  is  effected  during  the  first  few  days  by  a 
simple  trough  for  the  forearm.  At  the  end  of  seven 
or  eight  days,  when  the  infection  has  been  arrested 
and  suppuration  has  almost  ceased,  a  temporary 
interrupted  plaster  should  be  made,  the  position  being 
one  of  supination.  This  type  of  appliance  has  already 
been  described  (fig.  79). 

It  is  often  useful  to  increase  the  rigidity  of  the 
exposed  part  of  the  forearm  by  incorporating  a  small 
wooden  splint  in  the  outer  part  of  the  dressing,  which 
acts  as  a  rigid  external  support.  It  is  applied  to  the 
internal  aspect  and  fixed  firmly  in  place  by  a  bandage. 
There  is  a  natural  tendency  to  angulation  of  the  bones, 
when  a  plaster  of  this  kind  is  used  which  does  not 
immobilise  by  any  means  perfectly,  and  this  tendency 
is  well  counteracted  in  the  way  described. 

This  appliance  is  merely  temporary.  As  soon  as  the 
wound  need  only  be  dressed  at  long  intervals,  it  is 
preferable  to  immobilise  in  the  usual  plaster  trough. 
Frequently,  in  cases  such  as  have  been  described,  pre- 
cautionary resection  of  the  ulna  should  be  performed. 
Its  indications  have  already  been  given  :  .if  the  ulna 
tends  to  adapt  itself  to  a  diminished  length  by  curvature, 
if  the  radiograph  shows  obliquity  of  the  radio-carpal  line 
and  distal  radio-ulnar  diastasis,  and  if  the  inter- 
fragmentary gap  exceeds  1  inch  in  width,  I  believe  it 
perferable  to  have  recourse  to  this  without  waiting 
for  actual  deviation  outwards  of  the  hand  to  take 
place. 

(c)  4  case  is  seen  with  a  sinus. — This  is  the  ordinary 
case  of  fistulous  osteitis,  and  the  usual  treatment  is 
required. 

{d)  A  case  is  seen  with  vicious  union  in  a  "position  of 
extreme  pronation. — This  position  is  extremely  trouble- 
some, and  seriously  interferes  with  the  functions  of 
the  hand.  It  is  due,  as  has  been  explained,  to  double 
rotation  in  opposite  directions  of  the  two  fragments 
of  the  shaft,   which  incorrect-  fixation  has  failed  to 


474  TREATMENT    OF    FRACTURES 

rectify.  This  vicious  disposition  must  be  broken 
down  to  permit  a  second  reduction  of  the  fracture. 

In  this  connection,  two  possible  cases  must  be 
considered : 

\st  Case.  The  callus  is  regular,  and  not  fistulous. — 
The  bone  as  a  whole,  instead  of  possessing  a  curvature 
with  a  convexity  outwards,  forms  an  angle  the  apex 
of  which  is  close  to  the  ulna.  The  best  course  is  to 
fracture  the  lower  fragment  at  some  distance  from  the 
callus.  An  osteotomy  is  therefore  carried  out  below 
the  fracture,  and  the  small  incision  required  for  this 
purpose  is  not  sutured,  since  plugging  and  drainage 
are  effective  in  stimulating  ossification  The  forearm 
is  at  once  immobilised  in  a  posterior  plaster  trough  in 
a  position  of  supination.  After  verification  by  a  radio- 
graph, the  appliance  is  kept  in  place  for  at  least  a 
month.  At  the  end  of  this  period  the  plaster  may 
be  removed  and  the  wound  dressed.  Fixation  should, 
however,  be  prolonged  for  a  further  fortnight  or  three 
weeks  in  order  to  obviate  a  return  to  semi-pronation 
by  torsion  of  the  soft  callus.  The  results  of  this 
operation  are  excellent ;  I  have  succeeded,  in  two 
cases,  in  reproducing  almost  normal  conditions. 

2nd  Case.  Fistulous  osteitis,  with  a  large  callus. — 
Suppuration  must  first  be  arrested  and  complete  cure 
obtained  the  method  described  in  the  preceding  case 
should  then  be  adopted. 

(e)  A  case  is  seen  with  pseudarthrosis . — Unlike  pseud- 
arthrosis  of  the  ulna,  that  of  the  radius  has  serious 
effects  :  extreme  pronation  is  induced  in  the  lower 
fragment,  the  supinators  being  unable  to  counteract 
this  ;  the  hand  is  deflected  outwards  and  is  impotent ; 
there  is  dropped  wrist  and  inability  to  grasp  with  the 
fingers.  The  curvature  of  the  ulna,  due  to  its  dispro- 
portionate length,  is  painful.  Intervention  is  a  neces- 
sity. _ 

If  the  gap  in  the  bone  is  not  more  than  |  mch  m 
width,  direct  osteosynthesis  by  plate  or  clip  is  possible. 


FRACTURES    OF    THE    FOREARM      475 


after  removal   of  the  intervening  fibrous  tissue  and 

trimming  of  the  extremities  of  the  bone.     But  this 

does  not  correct  the  deviation  of  the  hand,  and  thq 

uhiar    curvature    remains.     Even    in    these    cases    I 

prefer,  after  tiim- 

ming    the    radius, 

to  resect  from  the 

uhia    a    sufficient 

length  of  bone  to 

bring    about    per- 

f  e  c  t     reduction  ; 

union  in  the  radius 

then  follows  very 

rapidly. 

When  the  gap 
is  more  extensive, 
there  is  no  alter- 
native to  ulnar  re- 
section, but  the 
ulna  should  be 
fixed  at  once  by  a 
clip  or  plate,  as 
has  been  advised 
by  Nove  -  Josse  - 
rand.  If  this  pre- 
caution be  not 
taken,  cure  of  the 
radial  pseudar- 
throsis  will  often 
follow,  while  the 
surgical  fracture 
of  the  ulna  fails 
to  unite.  Nove- 
J  o  s  s  e  r  a  n  d  has 

quoted  cases  of  this.  I  myself  have  been  obliged 
in  two  cases  to  plate  the  ulna  again  when  union  had 
already  occurred  in  the  radius. 

By  this  method  consistent  results  will  be  obtained 


Fig.  88. — Fixation  of  the  hand  in  ex- 
treme pronation  following  a  seriously  in- 
fected fracture  of  the  radius,  cured  with 
a  pseudarthrosis.  Reduction  under  an 
anaesthetic  was  impossible.  Correction  of 
the  vicious  position  was  obtained  after 
osteotomy  of  the  ulna.  The  result  is  ex- 
cellent. The  hand  is  semi-pronated  with 
the  thumb  upwards,  small  movements 
sufficient  for  professional  purposes  being 
still  possible.  The  result  dates  from  ten 
months  previously. 


476  TREATMENT    OF    FRACTURES 

in  all  cases  where  the  width  of  the  interfragmentary 
gap  does  not  exceed  1^  inches.  The  same  cannot  be 
said  of  grafting,  which  many  surgeons  have  attempted 
with  few  successful  results  :  apart  from  its  serious 
technical  difficulty,  account  should  be  taken  of  suppura- 
tion, the  main  cause  of  its  failure,  to  which  it  is  rendered 
liable  by  the  presence  of  latent  organisms  in  the  bone 
and  soft  tissues.  I  have  seen  six  cases  at  medical 
boards  in  which  the  graft  had  been  eliminated  or  re- 
absorbed. 

Bone-grafting  can  therefore  not  be  recommended 
as  a  reliable  method  in  war-surgery.  Consequently, 
when  the  procedure  previously  described  (trimming 
of  the  radius  and  resection  of  the  ulna)  is  not  possible, 
the  problem  is  difficult  to  solve. 

In  a  case  of  pseudarthrosis  in  the  proximal  part  of 
the  bone,  I  obtained  satisfactory  results  from  simple 
corrective  osteotomy  of  the  ulna,  which  permitted 
restoration  of  the  hand  to  a  good  position.  The  result, 
which  dates  from  ten  months  ago,  has  been  maintained 
(fig.  88).  The  pseudarthrosis  is  not  cured,  but  the 
vicious  position  of  the  hand  is  corrected  by  what  may 
be  described  as  therapeutic  counter-torsion. 

Lastly,  if  there  is  very  extensive  loss  of  bone,  the 
best  solution  appears  to  me  to  be  inferior  radio-ulnar 
arthrodesis,  as  described  by  Nove-Josserand,  or  the 
production  of  radio-ulnar  synostosis  low  down,  sug- 
gested by  Ombredanne. 

B.  Fracture  of  the  Lower  Radial  Epiphysis. 

1.  Anatomical  Features. — Small  splinters  with 
irregular  extremities  are  frequently  formed,  their 
long  axes  corresponding  to  that  of  the  bone ;  the 
articular  surface  is  usually  intact,  and  frequently  the 
external  surface,  which  forms  the  prolongation  upwards 
of  the  styloid  process,  is  also  left  uninjured  ;  the 
epiphysis  is   partially  broken  up,   but    the  fracture. 


FRACTURES    OF    THE    FOREARM       477 

which  is  rarely  complicated  by  fissures,  usually  remains 
extra-articular. 

The  splinters  frequently  remain  in  place,  arranged 
in  parallel  formation,  and  separated  by  fissures  ;  the 
appearance  of  an  epiphysis  thus  composed  of  segments 
in  juxtaposition  is  very  characteristic. 

There  is  almost  always  association  of  serious 
injury  to  tendons,  and  often  laceration  of  the  radial 
artery. 

2.  Physiological  Features. — Little  muscular 
action  is  exerted  on  the  lower  fragment,  which  usually 
remains  in  place,  merely  inclining  slightly  upwards 
and  inwards  without  causing  any  dorsal  prominence. 
I  have  always  found  it  in  pronation,  either  because  the 
hand  was  in  this  position  when  the  injury  occurred,  or 
owing  to  continued  action  of  the  pronator  quadra tus. 
The  upper  fragment  assumes  a  position  of  supination, 
except  in  cases  where  the  fragments  are,  so  to  speak, 
entangled,  which  sometimes  occurs. 

The  study  of  a  few  fractures  by  bullets  causing 
punctiform  wounds  proves  the  reality  of  this  counter- 
torsion  :  I  have  twice  found  cases  which  healed  with- 
out suppuration,  and  were  cured  with  the  hand  fixed 
in  extreme  pronation  ;  not  the  slightest  degree  of 
supination  was  possible,  in  spite  of  complete  integrity 
of  the  joints  (including  the  lower  radio-ulnar  joint). 

In  actual  fact,  the  displacement  of  the  lower  frag- 
ment upwards  and  inwards  is  of  much  greater  ultimate 
importance.  Its  actual  result  is  to  shorten  the  radius, 
causing  outward  deviation  of  the  entire  hand,  and 
consequently  serious  future  functional  disturbance. 

3.  Course. — As  a  rule,  serious  local  infective  pheno- 
mena develop  rapidly,  and  their  intensity  depends  on 
the  extent  to  which  the  projectile,  in  traversing  the 
cancellous  tissue  of  the  epiphysis,  has  ground  into  it 
fragments  of  the  sleeve,  or,  as  frequently  happens, 
soil.  These  foreign  materials  are  also  found  beneath 
and  between  the  tendons.     Gas  gangrene  and  similar 


478 


TREATMENT    OF    FRACTURES 


infections  do  not  develop,  since  there  are  no  muscles 
in  the  region.  Tracks  of  pus  develop  along  the  tendons, 
beneath  the  skin,  which  is  swollen  and  tense,  and  the 
progress  of  the  infection  soon  outstrips  the  possibilities 
of  surgical  interference  ;  the  forearm  is  little  more 
than  a  purulent  sponge,  giving  rise 
to  constitutional  disturbance  which 
multiple  incisions  are  powerless  to 
arrest,  and  amputation  may  even- 
tually be  the  only  resource.  Even 
if  the  infection  is  successfully  con- 
trolled, the  muscles  undergo  scle- 
rosis, tendons  are  eliminated  or 
destroyed,  the  hand  remains  pur- 
plish and  oedematous,  and  function 
is  irremediably  lost. 

Earlier  intervention  is  therefore 
necessary :  the  situation  may  be 
controlled  by  an  operation  on  the 
bone  at  a  very  early  stage,  but 
even  in  this  case  the  tendons  are 
too  often  destroyed,  and  the  fingers 
remain  stiff  and  almost  useless. 

In  less  serious  cases,  chronic  in- 
fection of  the  fractured  region  de- 
stroys the  marrow  of  the  epiphysis  ; 
the  callus  which  forms  is  large  and 
peripheral,  concealing  a  central 
cavity  which  remains  fistulous  for 
a  long  period. 

Further,  sepsis  having  caused 
necrosis,  not  only  of  the  splinters 
but  of  the  extremities  of  the  epi- 
physis and  shaft,  the  bone,  already  shortened  by  the 
passage  upwards  of  the  lower  fragment,  is  very  much 
reduced  in  length,  and  the  callus  renders  this  shortening 
permanent.  At  the  same  time,  deviation  of  the  hand 
occurs,  and  ultimately,  when  the  wound  has  healed, 


Fig.  89.— Union  of 
an  intra-epiphyseal 
fracture  of  the  ra- 
dius, with  formation 
of  a  central  cavity  ; 
upward  displacement 
of  the  lower  radial 
fragment,  hand  de- 
viated to  the  radial 
side;  considerable 
interference  with 
movement.  Ortho- 
paedic resection  of  the 
ulna  was  indicated, 
and  would  have 
avoided  this. 


FRACTURES    OF    THE    FOREARM      479 

the  surgeon  is  surprised  to  find  serious  outward  de- 
flection of  the  hand. 

It  is  absolutely  necessary  to  obviate  these  unfortun- 
ate occurrences  and  to  ensure  a  good  recovery  of  the 
injured  region. 

4.  Indications  for  early  Treatment. — The  fol- 
lowing steps  should  be  taken  : 

{a)  Early  operative  disinfection  of  the  fracture, 
which  will  ensure  asepsis,  and  therefore  easy  mainten- 
ance of  a  satisfactory  reduction  ; 

(6)  Fixation  in  a  suitable  position  ; 

(c)  Early  operative  correction,  preventive  if 
necessary,  of  external  deviation  of  the  hand. 

Immediate  disinfection  is  effected  by  sub-periosteal 
esquillectomy  at  an  early  stage,  which,  judging  by  my 
own  experience,  should  in  this  case  be  total.  This  is 
a  delicate  operation,  since  the  splinters  are  small,  and 
their  periosteum  is  very  thin  and  adherent,  as  in  all 
epiphyseal  regions. 

The  fracture  is  approached  by  a  dorsal  incision,  in 
addition  to  which  a  palmar  incision  will  often  be 
necessary,  even  at  the  expense  of  sacrificing  the  radial 
arterv. 

The  epiphysis  and  medullary  canal  of  the  shaft  should 
be  scraped  out  with  great  care  ;  a  large  number  of 
small  fragments  of  bone  pulverised  by  the  impact 
will  usually  be  brought  to  light  in  this  way.  The 
tendons  should  be  carefully  examined,  and  it  is  for 
this  examination  that  a  palmar  incision  is  particularly 
necessary  ;  surprise  will  often  be  caused  at  what  is 
found  in  contact  with  them. 

This  process  of  cleaning  completed,  it  will  usually  be 
found  well  to  remove  a  certain  amount  of  bone  from 
the  dorsal  surface  of  the  epiphysis,  rather  than  leave 
the  latter  in  the  shape  of  a  completely  empty  shell. 
This  should  only  be  done  after  careful  removal  of  the 
periosteum  with  a  rugine. 

Immediate  repair  of  the  lacerated  tendons  will  often 


480 


TREATMENT   OF    FRACTURES 


be   possible  ;     it   should  preferably  be   effected  with 
catgut. 

The  wound  is  then  plugged  with  aseptic  gauze,  and 
the  forearm  immobilised  by  a  plaster  trough  in  a 
position  of  semi-pronation,  the  thumb  upwards,  and 


Fig.  90. — Fracture  of  the  lower  end  of  the  radius,  evacuated  from 
the  front  after  having  a  drainage  tube  passed  through  the  epiphysis 
(without  anaesthetic)  ;  wound  seriously  infected.  Total  esquillec- 
tomy  during  pyrexia  on  the  third  day  ;  a  number  of  pieces  of 
clothing  removed  from  close  contact  with  the  cancellous  tissue  of 
the  epiphysis  and  the  medullary  canal  of  the  shaft.  Saline  dress- 
ings, followed  by  aseptic  dressings.  Cure  without  pseudarthrosis 
in  three  months. 


the  hand  supported  on  its  ulnar  side.     During  the 
first  few  days  I  believe  that  this  position  is  preferable 
to  that  of  supination,  which  renders  the  examination 
and  dressing  of  the  wounds  much  more  difficult. 
Fixation  should  first  be  effected  by  a  metal  splint, 


FRACTURES   OF    THE    FOREARM      481 

then,  at  the  end  of  some  days,  by  a  plaster  trough, 
applied  to  the  ulnar  side  of  the  forearm  and  reaching 
well  above  the  elbow. 

At  the  end  of  four  or  five  weeks  an  X-ray  examina- 
tion is  made.  At  this  stage  the  shadow  of  the  periosteal 
cylinder  will  usually  be  clearly  visible,  indicating  that 
callus  is  in  process  of  formation.  The  position  of  the 
styloid  process  of  the  ulna  and  the  direction  of  the 
radio-carpal  line  must  also  be  examined  closely.  If 
the  styloid  process, seems  to  be  situated  lower  down 
than  it  should  be,  if  it  descends  lower  than  the  styloid 
process  of  the  radius,  and  if  the  radio-carpal  line  is 
directed  obliquely  upwards,  preventive  resection  of 
about  half  an  inch  of  the  ulna,  followed  by  plating 
of  the  latter,  should  be  performed  without  delay 
(see  p.   471). 

After  the  operation,  the  forearm  is  immobilised  for 
five  weeks  in  the  position  of  supination,  unless  the 
radiograph  shows  injury  to  the  radio-ulnar  joint.  In 
this  case,  semi-pronation  with  the  thumb  upward  is 
preferable  as  a  permanent  position,  since  it  would  be 
hardly  reasonable  to  expect  recovery  of  the  power  of 
pronation  and  supination. 

5.  Treatment   of    cases    examined    at   a    late 

STAGE    OR    AFTER   PREVIOUS    TREATMENT. — [a)   A    case 

is  progressing  well  after  some  days,  without  operation. — 
There  is  no  pyrexia  or  suppuration  ;  all  that  is  neces- 
sary is  immobilisation  in  full  supination  for  a  month, 
the  hand  resting  on  its  ulnar  side,  in  order  to  counteract 
the  tendency  to  upward  and  inward  deviation  of  the 
lower  fragment,  and  therefore  to  prevent  displacement 
of  the  hand.  A  plaster  trough  is  the  best  fixation 
appliance  for  this  case,  and  in  many  cases  it  should 
be  left  in  position  for  more  than  a  month,  union  in 
epiphyseal  fractures  being  sometimes  very  slow. 

(b)  A  case  arrives  in  a  septic  condition. — After  deter- 
mining the  existence  and  position  of  splinters  and 
foreign  bodies  by  means  ot  a  radiograph,  total  sub- 


482 


TREATMENT    OF    FRACTURES 


periosteal  esquillectomy  should  be  performed  imme- 
diately. The  epiphyseal  cavity  and  medullary  canal 
are  cleaned  with  the  greatest  care,  tracks  of  pus  are 
followed  to  their  limits,  and  necrosed  tissue  is  excised. 
After  a  comprehensive  operation,  a  hypertonic  saline 

dressing  is  applied  to  the 
wound,  and  fixation  effected 
by  a  trough  splint. 

The  wound  should  be 
dressed  daily,  if  necessary 
under  an  anaesthetic  (ethyl- 
chloride).  Any  necrosed  de- 
bris or  small  fragments  of 
bone  which  have  been  over- 
looked are  removed  with 
forceps.  If  pus  has  tracked 
upwards,  this  should  be 
drained,  not  with  drainage 
tubes,  but  by  incising  the  skin 
over  the  affected  area.  Sep- 
sis will  usually  be  arrested  in 
five  or  six  days.  This  method 
has  up  to  the  present  always 
accomplished  my  object ;  I 
have  never  been  obliged  to 
amputate  in  such  a  case,  even 
in  those  that  have  first  come 
under  my  care  at  a  late  stage 
in  a  seriously  septic  condi- 
tion, and  I  have  never  lost  a  case  of  this  kind. 

(c)  A  case  is  seen  with  a  sinus. — This  almost  in- 
variably leads  to  a  cavity  in  the  interior  of  the 
epiphysis,  in  which  are  enclosed  splinters  which  were 
not  originally  removed ;  their  removal,  and  scraping 
of  the  cavity  is  usually  not  enough  to  effect  healing. 
The  cavity  must  first  disappear,  and  this  habitually 
necessitates  a  levelling-down  of  the  bone. 

{(l)  A   case  is  seen  with  a  pseudarthrosis . — In  this 


Fig.  91. — Radiograph 
after  two  and  a  half  months. 
Cf.  figs.  89  and  90. 


FRACTURES   OF    THE   FOREARM     483 

case  there  is  usually  outward  deviation  of  the  hand. 
The  styloid  process  of  the  ulna  forms  a  marked  pro- 
minence in  an  abnormally  low  position.  In  order  to 
effect  a  cure,  the  extremities  of  the  radius  must  first 
be  trimmed,  and  all  fibrous  tissue  between  them 
excised  ;  the  ulna  is  then  shortened  to  a  sufficient 
extent  to  correct  the  radial  inclination  of  the  hand, 


Fig.  92. 


Fig.  93. 


Fig.  94. 


Fig.  92. — Radial  pseudarthrosis  with  club-hand  after  fracture 
by  bullet,  never  operated  upon. 

Fig,  93.— ^The  same  case  seen  from  the  side. 

Fig.  94. — Cure  after  trimming  of  the  radial  extremities,  resection 
of  half  an  inch  of  the  ulna,  with  application  of  a  Lambotte  plate. 

and  at  the  same  time  to  approximate  the  two  fragments 
of  the  radius.  The  two  fragments  of  the  ulna  are 
united  by  a  clip  or  plate,  and  the  section  of  the  ulna 
removed  is  placed  in  the  interfragmentary  gap  of 
the  radius.  The  ulnar  wound  is  closed,  the  radial 
wound  plugged.  Careful  immobilisation  in  the  correct 
position,  prolonged  for  about  two  months,  will  enable 


484  TREATMENT    OF    FRACTURES 

union  to  take  place,  if  a  sufficient  length  of  the  ulna 
has  been  resected.  There  is  a  tendency  to  exercise 
economy  in  this  connection,  leading  to  failures  which 
could  well  have  been  avoided,  as  occurred  in  one  of 
my  own  cases.  On  the  other  hand,  I  have  twice  been 
successful  with  the  procedure  :  in  one  of  these  cases 
an  autoplastic  graft  had  previously  been  introduced 
and  reabsorbed  without  suppuration. 

III.   FRACTURES    OF   THE   ULNA 

1  shall  only  deal  with  fractures  of  the  shaft  of  the 
ulna  ;  fractures  of  the  olecranon  are  articular  fractures, 
requiring  sub-periosteal  esquillectomy  if  there  is  no 
other  fracture  present  *  and  re-resection  if  there  is 
associated  fracture  of  the  neighbouring  epiphyses. 
Fractures  of  the  styloid  process  are  comparatively 
trivial ;  after  prompt  esquillectomy,  they  heal  rapidly 
and  leave  no  functional  disability. 

Fractures  of  the  shaft  proper  require  separate  study. 

1.  Anatomical  Features. — These  fractures,  in  con- 
trast with  fractures  of  the  ulna  in  civil  life,  are  generally 
not  complicated  by  dislocation  of  the  upper  extremity 
of  the  radius.     It  is  easy  to  understand  why. 

All  types  are  possible,  but  the  most  usual  in  my 
experience  is  the  type  involving  one  large  short  frag- 
ment :  a  wedge-shaped  mass  is  detached,  and  rarely 
more  than  two  or  three  small  splinters  are  present  on 
the  other  side  of  the  shaft.  On  the  other  hand,  the 
projection  of  small  fragments  into  the  medullary  canal 
is  not  unusual.  Associated  injury  to  the  ulnar  nerve 
occurs  in  a  fairly  large  number  of  cases. 

2.  Physiological    Features. — It    is    a    constant 

*  In  very  favottrable  conditions  it  would  be  perfectly  possible, 
after  early  operative  disinfection,  to  treat  certain  fractures  of  the 
olecranon  as  peace-time  fractiires,  but  this  can  only  be  done  in  a 
quiet  sector,  where  the  possibility  of  close  supervision  is  guaranteed. 
In  the  event  of  large  numbers  being  admitted  or  evacuated,  any 
fovm  of  bone-suture  is  definitely  contra-indicated. 


FRACTURES    OF    THE    FOREARM 


485 


feature  that  the  upper  fragment  remains  in  position, 
while  the  lower  is  displaced  outwards  oy  the  powerful 
muscular  action  of  the  pronator  quadratus,  which 
forces  it  towards  the  shaft  of  the  radius,  with  which 
it  frequently  comes  into  contact,  and  difficulty  is  some- 
times experienced  in  reaching  it  unless  the  hand  is 
placed  in  supination. 

3.  Course. — This  is  not  a  serious  form  of  fracfure  ; 


Fig.  96 


Fig.  95. — Fracture  of  the  ulna  by  a  shell-fragment  with  fissures 
of  the  shaft ;  slight  infection.     Radiograph  on  the  fourth  day. 

Fig.  90. — Radiograph  eight  days  later,  after  sub-periosteal  esquil- 
lectomy. 

Fig.  97. — Radiograph  three  weeks  after  esquillectomy.  The 
fissures  are  no  longer  visible. 

Fig.  98. — Radiograph  on  the  thirty- fifth  day  when  healing  of  the 
soft  parts  has  been  complete  for  a  week  ;  post-operative  course  had 
been  aseptic.     (See  the  ultimate  result,  fig.  26,  p  330- 

owing  to  the  superficial  position  of  the  ulna,  the  area 
of  the  fracture  is  naturally  exposed,  and  it  is  only  in 
fractures  high  up  the  bone  beneath  the  thick  flexor 
muscles  that  serious  infections  occur. 
*  As  a  rule,  infection  merely  gives  rise  to  a  local 
affection  of  the  bone,  necessitating  incisions  and 
drainage,  and  ultimately  leaving  traces  of  its  existence 
in  the  form  of  a  cavity  in  the  bone,  enclosing  a  few 
small  sequestra. 


486  TREATMENT    OF    FRACTURES 

It  is  not  rare  for  pseudarthrosis  to  follow  suppuration 
in  these  cases.  It  is  true  that  pseudarthrosis  of  the 
ulna  is  not  a  serious  inconvenience,  but  that  is  no 
sufficient  reason  for  not  avoiding  it.  A  further  danger 
is  that  of  injury  to  the  flexor  muscles,  as  was  discussed 
on  p.  455 

4.  Indications  for  early  Treatment. — Here,  as 
in  other  regions,  sub-periosteal  esquillectomy  is  so  re- 
liable a  guarantee  against  asepsis,  that  if  there  is  an 
accompanying  injury  of  the  ulnar  nerve,  this  should 
be  sutured  at  once.  The  fracture  is  approached  by  a 
lateral  incision,  the  flexor  muscles  being  displaced  by 
a  retractor  if  the  level  of  the  injury  necessitates  this. 
Clearance  consists  in  separating  the  large  short  frag- 
ment with  a  rugine  as  well  as  the  few  small  isolated 
pieces  of  bone  found  in  the  region  of  the  fracture. 
The  medullary  canal  is  gently  cleaned  with  a  small 
curette  and  the  cavity  left  is  plugged  with  gauze. 
Fixation  is  effected  by  a  posterior  plaster  splint,  the 
forearm  being  supinated,  with  the  hand  flat  and  the 
elbow  flexed. 

In  general,  the  subsequent  course  is  uneventful,  and 
union  occurs  in  thirty  to  forty  days.  It  is  well  to  keep 
on  the  plaster  rather  longer  :  interrupted  appliances 
and  continuous  extension  are  useless. 

5.  Treatment   of  cases   first   seen   at  a  late 

STAGE  OR  AFTER  PREVIOUS  TREATMENT. (a)  A  Case 

arrives  going  on  well. — Fixation  of  the  forearm  in 
supination  is  all  that  is  necessary  ;  a  posterior  plaster 
trough  is  applied  for  this  purpose. 

(6)  A  case  arrives  in  a  septic  condition. — Immediate 
sub-periosteal  esquillectomy  is  essential  :  the  whole 
region  of  the  fracture  is  cleaned  through  a  fairly  long, 
lateral  incision,  all  splinters  being  separated  with  the 
rugine  and  removed.  During  this  process  the  con- 
dition of  the  flexor  muscles  should  be  carefully  ex- 
amined, as  small  splinters  are  frequently  found  in 
them   and   may   give   rise   to  .prolonged   suppuration 


FRACTURES    OF    THE    FOREARM     487 


which  has  a  serious  effect  on  muscular  contraction 
and  causes  grave  functional  disorder.  At  the  same 
time  all  devitalised  fascial  tissue  should  be  removed. 

This  treatment,  if  car- 
ried out  with  sufficient 
attention    to    detail,   and 


Fig.  99. — Narrow  sub-articu- 
lar pseudarthrosis  of  the  ulna, 
following  early  extra-periosteal 
esquillectomy.  The  wound 
healed  very  rapidly,  but  there 
was  no  regeneration  of  bone. 
The  continuity  of  the  ulna  is 
provided  by  a  narrow  osseous 
band,  in  contact,.with  the  shaft, 
but  not  united  to  it.  All  move- 
ments are  possible  and  almost 
normal. 


^a^js^ffi 

fln 

|M 

m  H 

II 

^^S 

^ 

^yJ^fflfoOTr^Jt!! 

i% 

m    1 

Fig.  100. — Removal  of  the 
lower  two-thirds  of  the  ulna  by 
extra-periosteal  resection  per- 
formed at  the  front.  The  patient 
was  cured  very  simply,  and 
there  is  virtually  no  disturbance 
of  function ;  pronation  and 
supination  are  performed  well, 
but  the  forearm  is  weak  :  a 
leather  wristlet  is  useful. 


not  merely  as  a  rapid  draining  process,  will  be  suc- 
cessful in  arresting  infection  and  safeguarding  the 
functions  of  the  hand,  which  would  be  permanently 


488  TREATMENT    OF    FRACTURES 

and  seriously  jeopardised  if  prolonged  suppuration 
took  place  in  contact  with  the  flexors  and  their  tendons. 
If  in  the  course  of  treatment  flexion  of  the  fingers  is 
seen  to  occur,  continuous  elastic  traction  should  be 
applied  without  delay  to  correct  their  position  and 
prevent  serious  cicatricial  contracture  (see  p.  455 ). 

(c)  A  case  arrives  with  a  sinus. — The  sinus  almost 
invariably  leads  into  a  small  cavity,  in  which  is  a  small 
sequestrum  embedded  in  granulations.  Hypertrophic 
callus  and  extensive  formation  of  sequestra  do  not 
occur  in  the  ulna',  frequent  as  they  are  elsewhere. 
This  is  not  surprising,  when  the  usual  type  of  fracture 
of  this  bone  is  considered.  But  it  should  not  be 
supposed  that  it  is  sufficient  to  remove  the  osseous 
debris  and  scrape  the  walls  of  the  cavity  in  order  to 
cure  the  sinus.  In  these  cases  I  have  always  found 
the  medullary  canal  blocked  on  each  side,  forming  a 
closed  cavity  which  is  a  frequent  cause  of  subsequent 
trouble.  If  a  cure  is  to  be  assured,  it  is  absolutely 
necessary  to  clear  the  cavity  completely,  cut  down 
the  bony  walls  of  the  cavity,  and  reduce  the  infected 
area  to  a  smooth  and  regular  surface.  This  done,  rapid 
cure  will  be  effected  without  the  use  gf  antiseptics. 
If  necessary,  sub-periosteal  resection  of  the  infected 
section  of  bone  may  be  performed. 

{d)  A  case  is  seen  with  pseudarthrosis . — In  general, 
a  pseudarthrosis  of  the  ulna  causes  little  functional 
disability  of  the  forearm  and  hand.  In  the  lower  part 
of  the  bone  it  is  only  slightly  troublesome,  and  if  the 
patient  wears  a  leather  wristlet,  he  may  be  said  scarcely 
to  notice  it.  In  the  upper  half  of  the  bone  it  causes 
little  inconvenience.  If  the  loss  of  bone  is  extensive 
(1|  inches),  slight  curvature  sometimes  occurs,  due 
to  the  weight  of  the  hand  when  the  forearm  is  raised, 
but  this  is  not  a  constant  feature.  My  impression, 
based  on  the  observation  of  three  cases,  is  that  even 
more  extensive  loss  of  bone  (3  to  4  inches)  causes  no 
more  trouble  (fig.  100). 


FRACTURES    OF    THE    FOREARM      489 

In  fact,  the  disorder  in  function  is  not  usually 
sufficient  to  justify  intervention.  I  have  seen  a  dozen 
of  such  pseudarthroses  or  gaps  in  the  bone  without 
operating  on  one  of  them.  This  confirms  the  opinion 
of  Nove-Josserand,  who  advises  refraining  from  opera- 
tion, even  in  the  severer  forms.* 

*  A.  Broca,  in  his  recent  book  on  the  osteo-articular  sequelae  of 
gunshot  wounds,  is  of  the  same  opinion  (see  "The  After-effects  of 
Wounds  of  the  Bones  and  Joints,"  by  Prof.  Aug.  Broca,  Military 
Medical  Manuals,  University    of  London  Press). 


CHAPTER  xrv 

MULTIPLE  FRACTURES   OF  THE  UPPER  LIMB 

The  early  disinfection  of  fractures  by  sub-periosteal 
esquillectomy  is  never  more  urgently  required  than 
in  the  numerous  cases  which  occur  of  multiple  fractures 
caused  by  fragments  of  an  exploding  shell.  By  careful 
cleaning  of  all  the  wounds,  which  will  frequently 
amount  to  a  somewhat  lengthy  operation,  surprising 
results  may  be  relied  on  if  this  be  done  as  a  primary 
or  even  as  a  secondary  measure. 

Further,  it  can  be  laid  down  as  a  principle,  that 
when  muscles,  arteries,  and  nerves  are  not  destroyed 
to  such  an  extent  as  to  render  subsequent  use  of 
the  limb  totally  iipipossible,  amputation  should  not  be 
performed  for  multiple  fractures.  It  is  better  to  en- 
sure a  favourable  course  for  the  fractures  by  multiple 
sub-periosteal  esquillectomy,  since  much  may  be  ex- 
pected from  periosteal  regeneration. 

The  immediate  fixation  in  these  cases  can  only  be 
effected  by  a  large  trough  splint  :  Delorme's  flat  trough 
is  very  suitable  from  this  point  of  view.     A  satisfactory 

Fig.  101.  — Fracture  of  the  humeru  s  with  intra- medullary  missiles , 
fracture  of  the  radius  and  ulna,  of  the  fourth  and  fifth  metacarpals, 
and  of  the  metacarpal  phalanx  of  the  fourth  finger.  Multiple  wounds 
by  shell-fragments  on  the  upper  limb  and  thorax  ;  infection  of 
all  the  wounds.  Intra-febrile  sub-periosteal  esquillectomy  on  the 
fourth  day,  three  fingers  being  removed  owing  to  the  extent  of  the 
lesions  of  the  soft  parts.  Later,  sub-periosteal  resection  (nineteenth 
day)  of  the  lower  extremity  of  the  ulna.  Result  obtained  after 
two  and  a  half  months  ;  wounds  almost  completely  healed,  fractures 
united.  The  periosteal  reproduction  of  the  lower  extremity  of  the 
ulna  will  be  noted.  Manual  correction  of  the  flexion  of  the  humeral 
callus  was  possible. 

490 


Fig,  101 


491 


492 


TREATMENT    OF    FRACTURES 


appliance  may  be  built  of  wide  wooden  slats  the  length 
of  the  limb,  extending  from  the  shoulder  to  the  tips 
of  the  fingers. 

As  soon  as  possible,  however,  a  suspension  apparatus 
should  be  employed.  Cure  may  certainly  be  effected 
by  other  methods,  and  the  case  of  which  radiographs 
are  reproduced  (fig.  101)  was  kept  for  the  whole  period 
of  treatment  in  a  Delorme  trough. 

A  suspension  appliance,  however,  obviates  pain  ;  it 
is   also    more   convenient   for   dressing   and   may    be 


Fig.  102. — Continuous  extension  on  the  arm  and  wrist  in  a  sus- 
pension appliance,  for  shattering  of  the  humerus  and  radio-carpal 
fracture.  Esquillectomy  was  performed  in  the  case  of  the  humerus  ; 
the  wrist  was  resected.  For  some  days  continuous  extension  was 
made  on  the  hand,  the  bands  being  fixed  to  the  stirrup  of  the 
humeral  extension.  Weight  of  extension,  1,500  grammes  ;  counter- 
poise weight,  4  kilogrammes.     (The  frame  is  not  illustrated.) 

combined    with    continuous    extension.     In    short,    a 
better  result  is  obtained  at  less  inconvenience. 

Two  types  of  suspension  apparatus  may  be  used  : 
the  type  in  which  extension  is  applied  to  a  horizontally 
suspended  limb  (fig.  102),  or  another  in  which  the  arm 
is  extended  horizontally  and  the  forearm  vertically 
(fig.  65,  p.  428 ).  Experience  leads  me  to  recommend 
the  latter  from  all  points  of  view. 


FRACTURES    OF    THE    UPPER    LIMB    493 

The  arm  is  placed  in  a  hammock  with  continuous 
horizontal  extension  applied  above  the  elbow  ;  the 
forearm  is  flexed  and  suspended  at  right  angles ; 
traction  is  exerted  on  the  palm  of  the  hand  or  on  the 
fingers,  if  the  wound  is  very  low  down,  but  on  the 
proximal  part  of  the  wrist  if  possible.  Patients  readily 
become  accustomed  to  this  :  I  have  two  in  course  of 
treatment  at  the  present  time  for  double  lesion,  and 
both  fractures  are  progressing  as  uneventfully  as  could 
be  desired. 

I  have  frequently  treated  fracture  of  the  humerus, 
radius,  ulna,  and  metacarpus  in  the  same  patient. 
These  cases  gave  more  trouble  than  the  two  of  which 
I  have  just  spoken,  and  the  superiority  of  suspension 
fixation  seems  to  me  to  be  beyond  discussion. 


CHAPTER  XV 
FRACTURES  OF  THE  FEMUR 

Three  main  varieties  are  found  in  practice  : 

1.  Sub-trochanteric  fracture. 

2.  Fracture  of  the  shaft  proper. 

3.  Supra-condylar  fracture. 

I.  Sub-trochanteric  Fracture 

1.  Anatomical  Features. — There  is  almost  in- 
variably comminution,  the  largest  splinters  rarely 
exceeding  2  inches  in  length ;  frequently  the  violence 
of  the  impact  forces  them  far  into  surrounding  muscles 
and  into  the  medullary  cavity,  fragments  often  being 
found  in  contact  with  the  sciatic  nerve,  or  even  within 
it  ;  I  have  personally  removed  them  on  two  occasions 
from  the  nerve  trunk. 

The  end  of  the  shaft,  as  well  as  that  of  the  upper 
fragment,  are  usually  jagged  and  irregular,  but  not 
fissured.  I  have  never  seen  cracks  running  up  into 
the  thickness  of  the  trochanter  or  to  the  neck,  and  I 
believe  it  to  be  very  exceptional  for  fissures  to  produce 
an  articular  fracture  even  in  an  extensive  injury  of  this 
kind. 

There  is  very  often  considerable  muscular  damage, 
whether  the  skin  be  lacerated  or  not ;  in  some  cases  the 
femoral  vessels  are  injured  by  the  projectile,  and  the 
sciatic  nerve  is  often  torn  or  severed. 

2.  Physiological  Features. — Muscular  action 
displaces   the   upper  fragment  in  an  invariable  and 

494 


FRACTURES    OF    THE    FEMUR        495 

characteristic  way  :  the  muscles,  passing  from  the  pelvis 
to  the  trochanter,  the  psoas,  iliacus,  and  pectineus, 
displace  it  upwards  and  outwards,  and  it  assumes  a 
position  of  abduction,  flexion,  and  external  rotation. 

On  the  other  hand,  the  lower  fragment,  under  the 
influence  of  the  adductors,  is  carried  upwards  and 
inwards,  and  to  a  certain  extent  is  internally  rotated. 
Its  displacement  upwards  is  sometimes  such  that  it 
appears  to  be  riding  over  the  upper  fragment ;  in  any 
case  splinters  may  be  found  behind  the  latter,  a  point 
that  it  is  well  to  remember  from  the  operative  point  of 
view. 

As  a  matter  of  fact  the  displacement  of  the  upper 
fragment  is  the  more  important,  and  gives  the  distin- 
guishing feature  to  this  common  type  of  fracture 
(fig.  103). 

3.  Course. — Sub-trochanteric  fracture  is  a  very 
serious  injury,  which  often  leads  to  death  within  a  few 
hours  from  simple  shock,  or  by  secondary  infection 
unless  this  danger  is  met  by  early  operative  treatment. 

In  cases  which  run  their  course  with  only  a  mild 
focus  of  infection,  a  large  bony  callus  is  formed,  en- 
closing sequestra  which  are  difficult  to  find,  and  whose 
removal  does  not  always  bring  about  closure  of  the 
sinuses. 

On  the  other  hand,  unless  the  fracture  is  reduced 
with  a  careful  eye  to  its  physiological  features,  union 
may  fail  entirely,  or  may  occur  with  marked  deformity 
and  serious  shortening. 

If,  however,  the  fracture  is  treated  by  early  and 
thorough  operative  disinfection  which  preserves  the 
elements  essential  to  the  formation  of  bone  from  the 
periosteum,  and  if  an  intelligent  reduction  is  performed 
in  time,  perfect  structural  and  functional  recovery 
occur,  the  patient  suffering  no  deformity  and  very  little 
shortening.  I  have  in  my  wards  two  men  suffering 
from  this  variety  of  fracture  :  one  got  up  after  fifty- 
seven  days,   the  injury  being  completely  sound,  the 


496  TREATMENT    OF    FRACTURES 

other  after  eighty-two  days.  In  each  case  the 
callus  allowed  of  their  lifting  the  thigh  at  the  end  of 
forty-two  to  forty-five  days.  The  shortening  does  not 
exceed  half  an  inch. 

4.  Indications  for  early  Treatment. — In  sub- 
trochanteric fractures  serious  symptoms  usually  appear 
immediately  ,  the  patient  suffers  from  great  shock, 
from  which  it  is  very  difficult  to  rouse  him. 

Moreover,  owing  to  the  difficulty  of  transport,  cases 
are  often  not  seen  until  they  are  in  a  seriously  septic 
condition.  Consequently  it  is  more  true  of  fractures 
of  this  region  than  of  any  other,  that  immediate 
operations  are  the  exception. 

In  cases  of  shock,  immediate  operation  is  impossible  ; 
it  would  prove  fatal  by  augmenting  the  shock.  In  the 
absence  of  more  precise  theories  by  which  to  direct  the 
ideal  treatment  of  shock,  every  effort  should  be  made 
to  counteract  the  peripheral  vaso-constriction  :  with 
this  object  the  patient  is  kept  warm,  and  lying  down 
with  the  head  low,  complete  repose  is  induced  by 
an  injection  of  morphine,  and  camphorated  oil  and 
adrenalin  are  used  as  stimulants. 

In  a  few  hours'  time  the  operation  may  be  per- 
formed ;  it  should  be  rapid  and  merely  do  what  is 
urgently  required,  leaving  complete  esquillectomy  to 
a  later  stage.  In  any  case,  the  shock  does  not  render 
amputation  preferable  to  esquillectomy  ;  it  only 
indicates  an  operation  in  two  stages. 

What  should  be  done  if  shock  is  not  severe  ? 

Extensive  muscular  damage  and  the  existence  of 
arterial  lesions  only  rarely  contra-indicate  a  con- 
servative operation.  This  being  so,  the  best  course 
is  usually  to  trim  the  cut  muscular  surfaces  thoroughly 
with  scissors,  to  sacrifice  all  contused  soft  tissues,  and 
to  tie  all  bleeding  points  :  ligature  of  the  femoral  artery 
has  no  untoward  effect  on  the  fracture. 

If,  however,  the  extent  of  muscular  injury  is  really 
too  great,  if  there  is  a  large  hematoma  and  infiltration 


FRACTURES    OF    THE    FEMUR         4<)7 

of  blood  far  along  the  thigh,  and  if  the  limb  below  is 
purplish  and  cold,  amputation  cannot  be  deferred.  It 
should  be  a  flapless  section  at  the  level  of  the  fracture 
according  to  Pauchet's  method,  the  upper  fragment 
being  roughly  smoothed  off,  subsequent  trimming  of 
the  stump  being  necessary.  Amputation  is  less  drastic 
than  disarticulation,  and  is  always  preferable  to  it. 

In  short,  the  original  operation,  apart  from  certain 
exceptional  cases  (diffuse  arterial  hematoma,  exten- 
sive injuries  to  soft  parts),  can  generally  be  limited 
to  prophylactic  sub-periosteal  esquillectomy. 

5.  Technique. — Esquillectomy  should  be  performed 
through  a  long  external  and  slightly  anterior  incision  ; 
this  incision  at  the  site  of  election  is  always  preferable 
to  those  corresponding  to  the  wounds  of  entry  and 
exit,  which  lead  to  drainage  in  the  vicinity  of  blood- 
vessels, or  in  positions  only  accessible  with  difficulty 
for  the  purposes  of  dressing. 

When  the  deep  fascia  is  incised,  the  edges  immedi- 
ately come  together  and  close  the  wound,  so  that  there 
is  difficulty  in  exposing  the  injury  thoroughly  with 
retractors,  and  there  should  be  no  hesitation  in  making 
transverse  incisions  in  the  fascia  lata,  so  as  to  produce 
a  widely-open  wound,  distinctly  more  extensive  than 
the  area  of  the  fracture.  After  particularly  careful 
cleaning  of  the  soft  parts,  and  removal  of  foreign  bodies, 
sub-periosteal  esquillectomy  should  be  performed  on 
the  usual  lines.  Cleaning  of  the  medullary  canal 
and  the  cancellous  tissue  of  the  upper  fragment  should 
not  be  omitted  ;  in  several  cases  I  have  found  splinters 
embedded  high  up  in  the  cancellous  tissue  of  the  tro- 
chanter. There  should  be  no  fear  of  operating  too 
drastically  :  experience  shows  that  surgeons  never  go 
to  too  great  lengths,  and  too  easily  fail  to  explore  ade- 
quately, which  accounts  for  subsequent  suppuration. 
The  entry  and  exit  wounds  are  freed,  their  internal 
surfaces  being  completely  excised.  The  usual  aseptic 
gauze  dressing  is  applied. 


498 


TREATMENT    OF    FRACTURES 


The  most  delicate  part  of  the  treatment  now  arrives, 
that  of  immobilisation. 

Imynohilisation . — If  possible  {i.e.  unless  large  numbers 
of  urgent  cases  are  being  received,  or  immediate  evacua- 
tion is  neces- 
sary), these 
cases  should 
always  be 
treated  by  con- 
tinuous exten- 
sion in  a  po- 
sition of  marked 
abduction.  Any 
fi  X  a  t  i  o  n  ap- 
pliance not  ful- 
filling these  two 
essential  con- 
ditions can  only 
be  provisional, 
e.g.  an  ap- 
pliance foj- 
transport  ;  it 
should  not  be 
used  for  treat- 
ment. 

1    imagine   it 
is     unnecessary 

to  insist  on  the  inadequacy  and 
danger  of  even  the  laigest  metal 
troughs  :  it  is  better  to  fix  the  limb 
on  a  long  wooden  splint  firmly 
fixed  to  the  pelvis  by  a  spica  band- 
age. This  method  of  fixation  is  more  complete  and 
less  painful. 

Plaster,  jjarticularly  in  the  form  of  a  pelvi-dorso- 
pedial  splint,  immobilises  well  and  diminishes  pain,  but 
cannot  affect  reduction  of  a  displacement  ;  to  correct 
this,  even  powerful   traction   under  an   anaesthetic   is 


Fig.  103.— Sub-tro- 
clianteric  fracture  by 
bullet  (punctiform 
wounds).  The  radio- 
graph shown  here  was 
taken  when  the  case 
was  in  a  plaster  appa- 
ratus applied  at  the 
front  luider  })owerful 
traction.  It  shows  that 
ri>duction  has  not  been 
obtained. 


FRACTURES    OF    THE    FEMUR        4!)9 


insufficient.  In  several  cases  I  have  seen  immobilisa- 
tion effected  by  a  large  plaster  well  constructed  under 
continuous  extension,  but  in  no  case  was  reduction  of 
the  displacement  obtained  (see  fig.  103).  This  should 
cause  no  surprise 
when  the  magni- 
tude of  the  muscu- 
lar forces  exerted 
on  the  two  frag- 
ments is  considered. 
There  is,  however, 
a  more  important 
reason  for  this  fail- 
ure than  the  resist- 
ance afforded  by 
muscular  action ;  it 
is  the  direction  of 
the  displacement  of 
the  trochanteric 
fragment,  over 
which  we  have  no 
control.  It  is  there- 
fore necessary  to 
bring  the  lower 
fragment  into  line 
with  the  upper,  in 
other  \yords  to  ab- 
duct the  thigh  to 
45°  to  50°,  accord- 
ing   to    indications 

given  by  a  radiograph.  The  best  position 
cannot  always  be  obtained  at  once  ;  it  is  sometimes 
necessary  to  feel  one's  way  and  to  alter  the  direction 
of  the  traction.  Under  these  conditions  a  permanent 
rigid  appliance,  even  when  applied  with  the  aid  of  the 
X-ray  screen,  is  unsuitable,  and  a  rigid  appliance  is  an 
unsatisfactory  means  of  treating  sub-trochanteric  frac- 
tures.    It   is  excellent  for  transport   and    temporary 


Fig.  104.  - 
ease  as  fig.  103 
diograph  after  a  month 
of'  continuous  exten- 
sion in  a  position  of 
marked  abduction, 
in  a  suspension  ap- 
pliance :  reduction  was 
obtained ;  the  radio- 
graph was  taken  with- 
out the  fixation  ap- 
paratus .  Compare  the 
line  of  the  upper  frag- 
ment in  fig.  103  with 
the  same  axis  here. 


500 


TREATMENT    OF    FRACTURES 


fixation,  but  it  is  not  justified  in  any  other  circum- 
stances. Sub-trochanteric  fracture  should  therefore  be 
treated  by  continuous  extension  in  marked  abduction. 
For  this  purpose  the  suspension  apparatus  is  the  ideal. 
Details  of  its  construction  will  be  found  on  p.  527  ; 
for  the  present  I  am  dealing  only  with  essential 
points,  and  with  those  which 
are  peculiar  to  sub-trochanteric 
fractures. 


Fig.  105. — Suspension  appliance  :  continuous  extension  in  abduc- 
tion. Traction  of  8  kilogrammes.  For  the  sake  of  clearness  the 
curved  bars  connecting  the  side  wires  of  the  splint  frame  are  not 
represented.     Compare  with  figs.   115  and  117. 


Two  uprights  support  a  horizontal  bar  6  ft.  6   in. 
above  the  floor  level.     The  support  is  placed  in  the 


FRACTURES    OF    THE    FEMUR         50I 

necessary  position,  as  indicated  in  fig.  105.      It  is  well 
to  make  it  of  considerable  length. 

The  wire  splint  frame  is  suspended  from  the  hori- 
zontal bar,  and  consists  of  two  thin  iron  rods,  about 
36  in.  long,  -|  in.  wide,  and  \  to  \  in.  thick,  con- 
nected at  each  extremity  by  a  curved  metal  bridge, 
which  is  bolted  to  them.  Holes  are  drilled  at  the  ends 
of  the  horizontal  rods  to  receive  the  suspension  hooks. 

As  described  on  p.  380,  lengths  of  linen  are  pinned 
to  this  frame  to  form  a  sling-hammock. 

After  operation,  the  limb  is  placed  in  this  cradle, 
which  is  suspended  by  cords  from  two  pulleys,  arranged 
as  shown  in  fig.  105. 

A  weight  of  4  to  5  kilogrammes  is  usually  required 
as  a  counterpoise  ;  this  is  a  weight  sufficient  to  make 
the  splint  with  the  limb  in  position  remain  in  equili- 
brium in  any  desired  position.  The  angle  of  inclination 
of  the  splint  may  easily  be  regulated  by  moving  the 
central  pulley  supporting  the  weight. 

Continuous  traction  is  exerted  in  the  usual  way,  i.e. 
by  means  of  a  stirrup  of  adhesive  strapping,  passing 
up  the  limb  and  fixed,  not  (as  shown  in  fig.  105,  for  the 
sake  of  clearness)  by  circular  strapping,  but  by  bands 
wound  spirally  round  the  limb.  A  weight  of  3|  kilo- 
grammes is  used  at  first,  increasing  by  500  grammes 
daily,  until  it  has  reached  7  or  8  kilogrammes. 

The  right-angled  position  of  the  foot  is  maintained 
by  means  of  a  small  padded  board,  which  is  strapped 
within  the  frame  of  the  cradle. 

Progress  after  operation. — Dressing  is  usually  a  simple 
matter,  and  is  performed  without  disturbing  the 
patient ;  the  wounds  being  usually  clinically  aseptic, 
dressing  at  long  intervals,  which  is  very  desirable  during 
the  first  few  weeks,  is  almost  always  possible. 

As  a  rule,  healing  is  rapid,  and  is  complete  in  fifty 
to  sixty  days.  Sometimes  after  the  fortieth  day  the 
patient  is  under  the  impression  that  his  limb  is  solid. 
I  have  seen  a  patient  lift  the  thigh  and  move  it  in  all 


502 


TREATMENT   OF    FRACTURES 


directions  at  the  end  of  thirty-two  days.  No  reliance, 
however,  should  be  placed  on  this  apparent  proof  of 
solidity  ;  the  callus  is  still  soft,  and  extension  and 
fixation  must  be  kept  up  for  a  further  long  period,  or 


Fig.  106. 


Fig.  107. 


Fig.  100. — Sub- trochanteric  fracture  by  a  shell-fragment  after 
secondary  sub-periosteal  esquillectomy  (twelfth  day). 

Fig.  107. — Radiograph  on  the  sixtieth  day,  showing:  (1)  reduc- 
tion by  continuous  extension  in  abduction  in  a  suspension  appliance, 
and  (2)  the  periosteal  callus,  obtained  in  forty-eight  days. 

the  callus  is  liable  to  become  bent  and  give  rise  to 
marked  angular  deformity.  This  has  occurred  recently 
among  my  own  cases  (see  figs.  107  and  108),  and  for 
this  reason  I  emphasise  its  importance.     I  consider  an 


FRACTURES    OF    THE    FEMUR 


503 


immobilisation   of    100   to    120   days   necessary.     But 
long  before  this  the  limb  can  usually  be  restored  to  its 
normal  position  ;    in  about  fifty  days  the  callus  has 
a   sufficiently    firm 
hold   on   the  upper 
fragment   to  in- 
fluence its  position 
and    to      maintain 
reduction     if    con- 
tinuous traction   is 
maintained.    T  li  i  s 
should   be    verified 
by  X-ray  examina- 
tion. 

At  this  stage  the 
patient  may  with 
advantage  get  up, 
using  D  e  1  b  e  t '  s 
walking  appliance, 
which  is  described 
on  p.  537 . 

The  results  of 
t  r  e  a  t  m  e  n  t  con- 
ducted in  this  way 
are  excellent  :  the 
shortening  is  not 
usually   more  than 


I  to  1^-  in.  ;  move- 
ments of  the  knee 
are  gradually  re- 
gained after  two  or 
three  months  of 
massage  and  active 
movements.  In 
slioi't.  tliere  is  al- 
most complete  re- 
covery of  function 
not  unusual   to  see 


FiQ.  108. — Secondary  flexion  of  the 
callus  on  the  seventy-sixth  day,  the 
patient  having  begun  to  walk  on  the 
seventy-second  day.  The  action  of  the 
pelvi- trochanteric  muscles  has  come 
into  play,  when  the  abduction  extension 
was  removed.  The  same  apparatus  was 
reapplied  and  the  correction  of  the  de- 
formity was  obtained  without  difficulty, 
the  final  result  being  practically  iden- 
tical with  that  in  fig.  107. 

in  less  than  six  months,  and  it  is 
patients  able  to  resume  normal 


504  TREATMENT    OF    FRACTURES 

life    during    the    second    six     months     after     being 
wounded. 

6.  Treatment  of  cases  seen  at  a  later  stage, 
OR  AFTER  PREVIOUS  Treatment.^ — {a)  A  case  has 
progressed  well  without  operation ^ — The  treatment 
indicated  is  simply  immobilisation,  for  which  purpose 
the  best  appliance,  as  in  other  cases,  is  the  suspension 
and  traction  apparatus  described  above. 

Within  a  short  time,  however,  Delbet's  appliance 
will  be  useful,  and  will  allow  the  treatment  to  be 
carried  on  as  long  as  may  be  necessary. 

It  should  be  remembered  that  in  non-infected  com- 
minuted fractures,  as  for  instance  those  caused  by  a 
bullet  with  punctiform  wounds  (fig.  103),  union, 
though  sometimes  very  rapid  (twenty-eight  days  in  one 
case  in  my  experience),  is  often,  on  the  contrary,  fairly 
slow.  I  have  seen  a  case  in  which  it  failed  to  occur 
within  seven  months. 

(b)  A  case  that  may  or  may  not  have  been  operated 
upon,  arrives  in  a  septic  condition. — The  patient  may 
only  have  been  brought  in  after  lying  out  for  a  long 
time  (as  is  frequently  the  case  with  seriously  wounded 
and  helpless  men),  and  no  immediate  operation  will 
have  been  performed.  The  thigh  will  be  swollen  and 
freely  suppurating.  Complete  sub-periosteal  esquil- 
lectomy  should  be  performed  immediately,  as  has 
already  been  described ;  there  should  be  extensive 
removal  of  muscle,  and  the  smallest  bone-splinters 
should  be  carefully  searched  for,  and  adherent  splinters 
removed,  even  if  they  extend  for  some  distance  down 
the  shaft.  The  periosteum,  irritated  by  the  infection, 
will  always  form  a  solid  column  of  bone  in  such  cases, 
and  the  removal  of  3,  4,  or  5  inches  of  the  bone  may 
be  undertaken  without  hesitation,  if  the  surgeon  will 
have  sufficient  patience  to  separate  the  periosteum 
carefully  with  the  gouge.  In  these  cases  of  secondary 
esquillectomy,  the  callus  forms  very  rapidly  (I  have 
seen  an  interfragmentary  gap  6  inches  wide  filled  in 


FRACTURES    OF    THE    FEMUR         505 

this   way),    as   I    shall    describe   in   connection   with 
fractures  of  the  shaft  proper. 

(c)  A  case  is  seen  at  a  later  stage  of  infection. — The 
outlines  of  the  callus  have  already  appeared,  but  there 
is  profuse  suppuration.  It  would  be  extremely  rash 
to  undertake  a  complex  operation  in  a  deeply-seated 
region,  which  cannot  adequately  be  exposed.  Nothing 
should  therefore  be  done  beyond  the  removal  of  easily 
accessible  sequestra,  and  no  attempt  should  be  made 
to  clean  the  infected  region  completely.  The  policy 
is  to  avoid  the  spread  of  infection,  and  to  limit  the 
latter,  with  the  intention  of  operating  afresh  when 
the  stage  of  sinus-formation  is  reached.  After  the 
operation  it  will  be  found  well  to  employ  warm  moist 
dressings  for  the  first  few  days. 

{d)  A  case  is  seen  with  a  sinus. — A  radiograph  is 
absolutely  necessary  to  ascertain  the  cause  of  the  sinus 
and  determine  the  treatment.  Occasionally  the  case 
is  found  to  be  one  of  superficial  osteitis,  but  almost 
always  deep  osteitis  is  responsible,  originating  frequently 
from  a  small  sequestrum.  In  this  case,  promiscuous 
curetting  is  inadvisable,  and  indeed  injurious.  The 
diseased  area  should  be  localised  very  exactly,  as  a 
missile  is  localised,  and  a  methodical  search  should  be 
made  for  it,  by  the  shortest  route.  The  operation 
should  always  be  performed  on  a  comprehensive  scale,, 
otherwise  there  is  not  much  likelihood  of  getting  a 
good  result. 

(e)  A  case  is  seen  with  a  pseudarthrosis . — Almost 
invariably  pseudarthrosis  is  due  to  lack  of  reduction, 
but  suppuration  has  rendered  the  osseous  tissue  sterile, 
and  traction  combined  with  wide  abduction  is  not  able 
to  bring  about  union. 

A  cutting  operation  is  necessary  to  excise  the  inter- 
fragmentary fibrous  tissue,  and  to  bring  the  fragments 
into  apposition  by  a  metal,  suture. 

If  possible,  even  at  the  cost  of  detaching  the  in- 
sertions of  the  pelvi-trochanteric  muscles  with  a  gouge 


506  TREATMENT    OF    FRACTURES 

in  order  to  permit  easier  movement  of  the  upper 
fragment,  the  fracture  should  be  reduced,  and  the 
two  fragments  phiced  end  to  end.  Unfortunately 
this  ideal  can  only  rarely  be  realised ;  muscular  and 
aponeurotic  contractures  and  stiffness  of  the  joint 
prevent  effective  action  (a  difficult  matter  enough 
apart  from  these  considerations)  on  the  trochanteric 
fragment.  In  a  case  of  this  kind  I  confined  myself 
to  fixing  the  shaft  to  the  lower  surface  of  the  up^jer 
fragment  by  a  large  Lambotte  plate.  The  result  was 
good,  in  spite  of  a  shortening  of  2|  in. ;  the  patient  was 
able  to  walk  again,  after  a  year  of  absolute  helplessness. 

(/)  Vicious  union  is  found  to  have  occurred. — Ihere 
are  numerous  cases  in  which  the  result  obtained  must 
be  accepted,  mediocre  though  it  may  be  ;  when,  for 
instance,  the  radiograph  shows  an  enormous  mass  of 
osteitic  bone,  intervention  is  very  dangerous,  and 
probably  destined  to  complete  failure. 

If,  on  the  other  hand,  the  radiograph  shows  lateral 
union  by  a  callus  which  is  not  too  dense,  and  easily 
accessible,  the  question  of  fracture  of  the  callus  may 
be  discussed,  and  of  re-immobilisation  in  full  abduction 
to  reduce  the  deformity.  But  this  decision  should  not 
be  come  to  lightly  ;  the  operation  is  always  difficult 
and  doubtful  in  its  results,  and  can  only  be  undertaken 
in  favourable  cases. 

After  osteotomy  of  the  callus  involving  as  little 
injury  as  possible,  the  wound  is  left  open,  without 
suture,  and  simply  plugged  with  moist  gauze  ;  if  it 
is  closed,  recurrence  of  infection  is  to  be  feared  even 
if  drainage  is  arranged  for,  and  the  best  means  of  avoid- 
ing all  post-operative  complications  is  to  keep  every- 
thing exposed,  resisting  the  temptation  to  sew  the 
wound  up  round  a  large  drainage  tube. 

I  am  also  of  opinion  that  it  is  better  not  to  correct 
the  faulty  position  by  sudden  force,  when  the  callus 
has  been  broken,  existing  conditions  are  allowed  to 
remain,  and  continuous  extension  is  exej'ted  with  the 


FRACTURES    OF    THE    FEMUR        507 

lower  fragment  in  its  original  position,  without  im- 
mediate correction.  Progressive  abduction  to  the 
necessary  degree  is  effected  gradually  during  the  days 
following. 

By  this  procedure  in  a  case  of  this  kind  I  obtained 
an  excellent  result  without  causing  the  slightest  degree 
of  pyrexia. 

II.   Fractures  of  the  Shaft :    the  so-called  Fractures 
of  the  Thigh 

1.  Anatomical  Features. — There  is  extreme  diver- 
sity of  anatomical  form  in  fractures  of  the  thigh.  All 
known  types  of  fracture  may  be  encountered ;  the 
most  usual  is  the  large-splintered  type,  more  or  less 
resembling  the  classical  "  butteffly-wing "  fracture. 
An  almost  constant  feature  is  the  presence  of  one  or 
two  large  longitudinal  splinters,  roughly  diamond- 
shaped,  and  tapering  to  sharp  points  at  a  great  distance 
from  the  actual  seat  of  fracture  ;  they  often  measure 
6  inches  and  more  in  length,  and  are  adherent  by  their 
periosteum  to  the  muscles  attached  to  them. 

In  the  middle  of  the  thigh  there  is  often  an  internal 
fragment  very  adherent  to  the  insertions  of  the 
adductors,  and  when  it  is  separated  with  the  rugine, 
the  impression  is  produced  that  the  larger  part  of  the 
bone  has  been  removed  ;  in  reality,  the  splinter  amounts 
only  to  a  narrow  strip,  the  removal  of  which  does  not 
diminish  the  future  solidity  of  the  bone,  if  the  peri- 
osteum has  been  preserved  carefully. 

Large  and  small  splinters  are  often  forced  a  great 
distance  into  the  muscles. 

The  damage  to  the  muscles  is  usually  very  con- 
siderable, but  it  is  frequently  situated  beneath  the 
scarcely  lacerated  deep  fascia.  A  muscular  hernia 
projects  through  a  small  unyielding  opening  in  the 
fascia,  and  the  wound  appears  inconsiderable,  but  if 
the  fascia  is  opened  up,  the  deep  muscles  are  found 


508  TREATMENT    OF    FRACTURES 

lacerated  and  destroyed,  with  areas  of  interstitial 
haemorrhage  well  beyond  the  immediately  damaged 
area  ;  their  ragged  edges  come  together  and  form  a 
rigid  curtain  closing  in  the  region  of  muscular  destruc- 
tion, in  which  are  splinters,  clots,  and  fragments  of  the 
projectile. 

Simultaneous  injury  to  vessels  or  to  nerves  may 
occur,  but  is  not  common. 

I  have  twice  seen  an  irregular  indirect  fracture,  situa- 
ted at  some  distance  from  the  splintered  region  (fig.  119). 

2.  Physiological  Features. — Owing  to  the  de- 
velopment and  strength  of  the  muscles  surrounding 
the  femur,  there  is  virtually  always  displacement  of 
the  fragments  in  fractures  of  the  thigh,  and  as  a  rule 
this  is  considerable.  The  forces,  which  are  normally, 
in  equilibrium,  are  arranged  in  antagonistic  groups; 
fracture  destroys  the  equilibrium,  and  the  fragments 
are  displaced  in  the  direction  imposed  on  them  by  the 
group  of  ihuscles  whose  insertions  are  most  completely 
preserved  and  whose  action  therefore  inevitably  be- 
comes predominant. 

There  are  five  principal  groups  of  muscles  whose 
actions  are  dissociated  by  fracture  : 

The  pelvi-trochanteric  group,. which,  acts  on  the  upper 
third  of  the  shaft,  from  the  trochanter  downwards, 
and  causes  outward  rotation  of  the  thigh,  with  ab- 
duction and  slight  flexion  on  the  pelvis. 

The  adductor  group,  which  comes  into  play  when  the 
fracture  is  obliquely  directed  from  above  downwards 
and  inwards  at  the  junction  of  the  middle  and  lower 
thirds  of  the  shaft ;  it  adducts  the  upper  fragment, 
slightly  flexes  it,  and  rotates  it,  either  outwards  or  in- 
wards, according  to  the  condition  of  the  lower  part  of 
the  adductor  magnus,  which  causes  inward  rotation. 
If  the  fracture  occurs  above  this  part  of  the  muscle, 
its  action  is  excluded,  and  external  rotation  occurs. 
This  is  usually  the  case,  and  results  in  torsion  which 
causes  considerable  interference  with  walking,  but  less 


FRACTURES    OF    THE    FEMUR         509 

serious  trouble  than  would  be  carused  by  an  uncorrected 
displacement  in  the  opposite  direction.  This  external 
rotation  is  not  surprising,  when  the  posterior  plane  of 
the  adductor  insertion  is  considered. 

The  long  posterior  muscle  group  (biceps,  semimem- 
branosus, semitendinosus)  which  normally  flex  the  leg 
on  the  thigh.  In  fractures  situated  below  the  upper 
third,  these  contribute  to  the  posteTior  upward  dis- 
placement of  the  lower  fragment  and  of  the  leg.  This 
upward  movement  is  never  direct ;  there  is  always 
slight  adduction  or  abduction  due  as  much  to  the 
injury  as  to  muscular  action. 

The  muscular  envelope  formed  by  the  quadriceps 
jemoris  which  produces  vertical  upward  displaceni^^nt 
of  the  lower  fragment. 

The  gastrocnemius  and  soleus  which  normally  exert 
no  action  on  the  thigh,  rotate  the  lower  fragment 
backwards  around  the  transverse  axis  of  the  condyles 
when  the  fracture  is  at  the  lower  end  of  the  bone  ; 
this,  however,  only  happens  in  supra-condylar  fractures 
with  which  we  are  not  at  present  concerned. 

It  results  from  all  this  that  the  following  displace- 
ments may  occur  in  fractures  of  the  shaft : 

Marked  over-riding,  sometimes  to  the  extent  of  3  to 
4  inches.  This  is  due  to  posterior  displacement  upwards 
of  the  lower  fragment,  caused  by  the  muscles  surround- 
ing and  attached  to  it,  and  by  the  posterior  muscles  of 
the  thigh  arising  from  the  pelvis. 

Lateral  displacement  in  a  direction  varying  according 
to  the  position  of  the  fracture.  In  fractures,  in  the 
upper  third  of  the  shaft,  the  pelvi-trochanteric  muscles 
cause  abduction  and  external  rotation  of  the  upper 
fragment,  the  lower  extremity  of  which  partially 
penetrates  the  muscles,  and  causes  a  prominence  be- 
neath the  skin  ;  there  is  therefore  marked  angulation, 
apex  outwards,  between  the  two  fragments  :  the  curva- 
ture which  often  persists  after  union  arises  in  this  way. 

In  fractures  of  the  middle,  and  notably  of  the  lower 


510  TREATMENT   OF    FRACTURES 

third,  of  the  shaft,  an  opposite  displacement  occurs  : 
the  adductors,  whose  insertions  are  generally  intact, 
counteract  the  action  of  the  pelvi-trochanteric  group, 
or  overcome  it,  and  the  upper  fragment  therefore  re- 
mains in  place  or  is  adducted,  while  the  lower  is  pulled 
outwards  and  upwards  behind  it. 

A  simultaneous  antero-posterior  displacement,  due  to 
flexion  of  the  upper  fragment  on  the  pelvis  and  to 
slight  rotation  backward  of  the  lower  fragment  caused 
by  the  calf  muscles.  As  a  result  of  this,  the  upper 
fragment  is  more  or  less  markedly  displaced  forwards. 
Rotation  on  the  long  axis  of  the  bone,  usually  external, 
and  principally  due  to  the  adductors,  and  to  the  weight 
of  the  limb. 

It  is  of  importance  to  emphasise  the  strength  of  the 
muscular  actions  Avhich  produce  these  displacements 
of  the  femur  ;  it  is  such  that  no  manual  force  can  over- 
come it,  and  immediate  reduction  is  impossible,  even 
with  anaesthesia.  It  should  be  remembered  that 
muscular  action  is  more  powerful  when  the  limb  is 
extended  in  a  straight  line  ;  if  the  thigh  is  flexed  on  the 
pelvis  and  the  leg  is  flexed  on  the  thigh,  muscular  relaxa- 
tion is  immediate  and  correction  easier.  The  surgeon 
may  easily  verif}^  this  on  himself,  and  after  this  simple 
experiment  he  will  easily  understand  the  physiological 
rules  for  reducing  fractures  of  the  thigh. 

It  should  also  be  remembered  that,  as  a  rule,  the 
contracting  muscles  carry  with  them  splinters  which 
are  thus  displaced  in  unexpected  directions ;  no 
fracture  yields  more  surprises  during  an  operation 
than  does  a  fracture  of  the  thigh. 

3.  Course. — Many  cases  of  comminuted  fracture 
die  rapidly  from  shock  and  haemorrhage.  The  initial 
haemorrhage  is  very  alarming  ;  no  one  who  has  not 
seen  these  cases  when  they  are  picked  up  can  have 
any  idea  of  the  loss  of  blood.  The  first  impression  is 
that  a  serious  vascular  lesion  exists,  but  this  is  generally 
not    the    case.     Haemorrhage,    however,    contributes 


FRACTURES    OF    THE    FEMUR  511 

largely  to  the  immediate  danger  in  certain  cases  which 
do  not  often  pass  the  first  surgical  line  (relai). 

Of  the  less  seriously  wounded  cases  which  recover 
from  the  initial  shock,  the  majority  are  liable  to  rapidly 
developing  gas  gangrene,  diffuse  cellulitis,  or  acute 
osteomyelitis,  and  these  are  fatal  if  the  necessary 
intervention  is  not  undertaken  in  time  :  difficulty  in 
collecting  the  wounded  gives  time  for  infection  to 
develop  and  greatly  favours  the  severe  and  often 
fulminating  forms  of  the  latter.  Other  cases  almost 
always  exhibit  secondary  infection,  which  n^ay  call 
for  the  gravest  decisions. 

Thus  the  principle  of  early  operation  in  cases  for 
whom  transport  is  impossible  has  become  a  dogma. 
But  it  is  difficult  to  do  just  as  much  as  and  not  more 
than  is  necessary.  Superficial  cleaning  is  always 
insufficient ;  esquillectomy  limited  to  free  fragments 
only  does  not  2:)revent  the  development  of  acute  in- 
fections and  profuse  and  persistent  suppuration,  the 
outward  sign  of  central  osteomyelitis,  the  results  of 
which  are  very  serious  ;  tracks  of  pus  requiring  pro- 
longed drainage  destroy  the  muscles  ;  infection  of 
the  fracture  area  destroys  the  bone-marrow  ;  finally, 
the  irritated  periosteum  proliferates  rapidly,  and  en- 
closes diseased  or  dead  fragments,  just  as  the  new  bone 
in  adolescent  osteomyelitis  invaginates  sequestra  (fig.  9, 
p  303).  The  periosteal  proliferation  is  almost  always 
adequate  to  reproduce  continuity  of  the  bone,  and 
pseudarthrosis  in  the  shaft  of  the  femur  is  rare,  but  a 
pathological  callus  is  very  common. 

Moreover,  owing  to  the  gravity  of  the  local  phenomena 
of  sepsis,  and  the  difficulty  of  frequent  and  painful 
dressings,  it  is  imjoossible  to  secure  immobilisation  in 
good  position  during  a  long  period  of  supj^uration  ; 
frequently  the  callus  consolidates  in  a  few  days,  leaving 
considerable  deformity  and  shortening,  and  the  ortho- 
psedic  result  is  bad. 

Meantime,  the  patient  is  obliged  to  remain  in  bed 


512  TREATMENT    OF    FRACTURES 

and  the  knee  becomes  stiff  and  equinus  develops  ; 
movements  of  the  knee-joint  are  so  limited  that  there 
is  almost  ankylosis,  a  fibrous  ankylosis  which  will 
certainly  deserve  the  name  unless  the  condition  is 
much  improved  by  massage  and  movements. 

In  short,  infected  fractures  oi  the  thigh,  generally 
because  of  inadequate  esquillectomy,  occasionally  but 
rarely  recover  by  the  formation  of  a  regular  and  healthy 
callus  ;  sometimes  the  superficial  surface  of  the  latter 
is  infiaiiied,  owing  to  a  small  sequestrum,  and  is  then 
easily  curable ;  much  more  often  there  are  sinuses  ; 
there  is  osteomyelitis,  and  union  is  bad  ;  the  patients, 
with  muscles  atrophied  and  joints  stiff,  remain  liable 
to  sudden  recurrence  of  infection  ;  the  limb  is  still 
there,  but  function,  if  not  completely  lost,  is  at  least* 
considerably  reduced  in  value. 

4.  Indications  for  early  Treatment,  {a)  Am- 
putation.— A  conservative  operation  is  not  always 
possible  in  the  thigh,  and  there  are  conditions  in 
which  the  necessity  for  amputation  must  be  recog- 
nised. Before  sepsis  is  evident,  these  indications  are 
not  very  frequent ;  they  are  furnislied  by  the  extent 
of  the  injuries  to  soft  parts,  the  extent  of  injury  to  the 
bone,  or  by  the  intensity  of  the  shock. 

(i)  If  there  is  muscular  destruction  involving  half 
the  posterior  aspect  of  the  thigh,  accompanied  by 
severance  of  the  sciatic  nerve,  or  if  the  anterior  muscles 
are  non-existent  over  a  wide  area,  amputation  is,  in 
my  opinion,  preferable  to  any  attempt  at  preservation. 
Sepsis  may  be  avoided,  and  its  effects  would  not  per- 
haps be  very  severe  in  these  widely  open  wounds  ;  but 
repair  is  almost  impossible—a  repair,  that  is,  compatible 
with  satisfactory  function  of  the  limb  :  the  patient 
would  become  an  invalid,  and,  what  is  more,  an  invalid 
with  a  painful  wound.  Hence  a  suitable  amputation, 
leaving  a  stump  consisting  of  such  healthy  tissue  as 
remains,  is  often  preferable  to  attempts  to  preserve 
the  limb. 


FRACTURES    OF    THE    FEMUR  513 

(ii)  If  the  femur  is  badly  comminuted,  i.e.  practically 
destroyed  for  6  to  8  inches  of  its  length,  as  is  the  case 
in  certain  wounds  of  an  explosive  type,  the  same 
remarks  apply  :  the  orthopaedic  result  is  too  doubtful 
to  justify  either  the  trouble  involved  or  the  risk  that 
will  be  run. 

(iii)  In  cases  which  only  rally  feebly  from  their  shock, 
in  whom  a  rapid  operation  is  desirable,  and  a  long  one 
is  out  of  the  question,  amputation  may  be  necessary 
to  transform  a  lacerated  into  a  clean  dry  wound  which 
involves  no  organic  strain  during  repair ;  such  a 
procedure  makes  for  safety. 

On  the  contrary,  if  there  is  an  accompanying  vascular 
lesion  (of  the  femoral  artery  or  vein),  a  conservative 
operation  should  be  performed,  after  ligature  of  the 
vessels  affected.  It  goes  without  saying  that  ischsemic 
gangrene  of  the  leg  demands  immediate  amputation. 

On  the  whole,  early  amputation  is  only  called  for 
exceptionally.  It  is  performed  in  the  usual  way,  with- 
out sutures ;  the  flapless  operation  should  be  reserved 
for  infected  fractures. 

(6)  Sub- periosteal  Esquillectomy. — Whenever  a  con- 
servative operation  seems  possible,  free  sub-periosteal 
clearance  is  the  only  means  constantly  and  under  all 
circumstances  to  ensure  the  legular  formation  of  a 
healthy  callus,  combined  with  clinical  asepsis  of  the 
wound. 

This  operation  is  done,  not  to  carry  out  an  extensive 
resection  of  the  shaft,  but  to  explore  the  wound  com- 
pletely and  remove  anything  which  blocks  it  and  con- 
verts it  into  a  closed  cavit}',  as  well  as  any  infecting 
foreign  body,  missile,  fragments  of  clothing,  free 
splinters,  fragments  of  dead  or  devitalised  tissue 
either  near  or  within  the  bone — everything,  in  fact, 
that  experience  shows  is  destined  to  become  gangrenous 
owing  to  contusion  or  infection.  The  interfragmentary 
gap  should  be  clean,  and  it  should  be  possible  to  apply 
a  dressing  direct  to  it  without  difficulty.     In  order  to 


514  TREATMENT    OF    FRACTURES 

effect  this,  any  adherent  splinters  that  conceal  the 
medullary  canal  should  be  removed  :  if  the  surgeon 
knows  how  to  use  the  rugine  with  patience,  too  much- 
cannot  be  removed,  since  all  elements  necessary  for 
repair  are  left  in  the  wound, 

I  emphasise  these  fundamental  points  because  their 
application  is  nowhere  more  necessary  or  more 
difficult  than  in  the  femur.  This  difficulty  is  due  to 
the  depth  of  the  injury,  to  the  bulk  of  the  muscles 
surrounding  the  bone,  and  to  the  resistance  of  the 
fasciae  enclosing  them,  all  of  which  points  also  explain 
the  gravity  of  these  fractures. 

As  far  as  possible,  intervention  should  not  be  under- 
taken during  the  phase  of  shock  ;  the  patient  is  kept 
warm,  and  should  receive  an  intravenous  injection  of 
adrenalin  (0  5  cc.  of  a  1  in  1,000  solution)  and  "01  gm. 
of  morphine,  while  favourable  developments  are 
awaited.  When  warmth  returns,  and  the  temperature 
has  become  normal,  and  the  blood-pressure  has  risen 
sufficiently  (above  10  by  Pachon's  appliance)  operative 
disinfection  is  carried  out. 

5.  Technique. — (a)  The  Operation. — The  operation 
is  performed  under  ether  or  spinal  anaesthesia,  after 


Fig.   109. — ^The  shaded  area  indicates  the  region  in  which  inter- 
vention should  not  be  undertalcen. 

X-ray  examination  and  localisation  of  foreign  bodies 
if  possible.  The  patient  should  be  in  a  slightly  inclined 
position,  with  the  head  low  (to  counteract  the  shock 
and  bulbar  anaemia). 

When  the  dimensions  of  the  existing  wounds  do  not 


FRACTURES    OF    THE    FEMU'R        515 

absolutely  force  the  surgeon  to  aj^proach  the  fracture 
through  one  of  them,  an  incision  should  be  made  at 
the  site  of  election,  that  is,  on  the  external  aspect  of 
the  thigh.  The  limh  is  slightly  flexed  on  the  'pelvis  in 
order  to  relax  the  obstructing  muscles.  This  is  of  great 
importance. 

The  wounds  are  first  cleaned,  and  all  contused, 
lacerated,  or  devitalised  parts  are  widely  excised. 
When  the  region  of  the  fracture  is  approached,  large 
retractors  are  introduced  and  the  wound  well  exposed 
and  freed  completely  from  any  foreign  matter.  A 
longitudinal  incision  is  now  made  at  the  site  of 
election  with  clean  instruments.  The  incision  should  be 
external,  rather  than  antero-external ;  anterior  in- 
cisions are  bad,  because  the  scar  in  the  muscles  fixes 
the  thigh  in  extension.  The  wound  should  be  4  inches 
at  least  in  length,  and  its  exact  position  wrill  vary 
according  to  the  situation  of  the  wounds  already  exist- 
ing. The  fascia  is  incised  for  the  same  distance  and 
also  nicked  transversely,  since  otherwise  its  tense 
edges  cannot  be  separated  satisfactorily,  and  tend  to 
reclose  the  wound.  The  vastus  externus  is  incised, 
bleeding  points  are  tied,  and  the  bone  is  reached. 
When  the  fracture  is  exposed,  two  large  retractors  are 
introduced,  and  the  injury  is  examined. 

Two  conditions  may  be  found  :  either  comminution 
has  occurred,  or  the  fracture  is  of  the  long-splinter 
type. 

la  the  former  case,  careful  clearance  with  the  rugine 
and  forceps  is  required.  Everything  entirely  free  is 
removed  with  forceps,  then,  the  wound  being  clean, 
the  periosteum  is  separated  with  the  greatest  care  from 
splinters  which  are  loose,  but  still  attached  to  the 
former.  Some  surgeons  believe  that  in  these  cases 
it  is  impossible  to  attempt  to  preserve  the  periosteum, 
and  that  no  one  who  had  ever  seen  a  comminuted 
fracture  would  suggest  sub-periosteal  esquillectomy. 
Their  opinion  is   worthless,  .and  merely  proves  that 


516  TREATMENT    OF    FRACTURES 

they  are  poor  operators,  lacking  in  care  and  patience, 
and  no  value  should  be  attached  to  these  ready-made 
opinions.  The  fragments  situated  close  to  the  ends 
of  the  shaft  should  first  be  located,  and  their  periosteal 
covering  will  easily  be  detected ;  from  this  point  it 
will  be  possible  to  strip  the  fragments  completely,  and 
when  the  operation  is  concluded,  there  will  be  the 
satisfaction  of  finding  a  clearly  visible  channel  of 
periosteum,  lacerated,  it  is  true,  but  forming  a  resistant 
whole. 

If  the  splinters  are  large,  after  removing  those  that  are 
free,  the  periosteum  is  separated  from  adherent  splinters 
which  require  removal,  by  grasping  them  firmly  with 
forceps  and  carefully  using  the  rugine  upon  them, 
cutting  well  down  into  the  bone  ;  this  will  preserve 
intact  an  invaluable  periosteal  sheath  around  the  end 
of  the  shaft. 

It  is  difficult  to  say  exactly  how  far  the  removal  of 
adherent  splinters  should  be  carried  in  the  pre-inf  ected 
stage  :  it  is  scarcely  ever  necessary  to  remove  all  of  them  ; 
it  is  necessary  and  sufficient  that  dressings  should  be  able 
to  be  applied  direct  to  the  fractured  region,  after  complete 
exploration  of  the  latter. 

It  is  therefore  an  affair  of  judgment  and  experience. 
There  is  a  general  tendency  not  to  remove  enough,  and 
nruch  determination  and  experience  are  necessary  to 
perform  a  sufficiently  comprehensive  operation  and 
expose  the  region  thoroughly. 

After  ligature  of  every  bleeding  point  and  careful 
cleaning  of  the  whole  wound,  the  gap  between  the 
bones,  which  is  now  of  regular  proportions,  is  loosely 
packed  with  aseptic  gauze,  and  the  wounds  are  left 
Unsutured.  A  counter-incision  for  drainage  is  useless  ; 
I  never  make  one,  even  in  secondary  esquillectomies, 
and  I  have  never  regretted  it. 

Fractures  complicated  by  vascular  lesions  require  no 
special  treatment,  other  than  the  necessary  ligature. 
In  wounds  complicated  by  injury  to  the  knee-joint, 


FRACTURES    OF    THE    FEMUR         517 

which  are  sometimes  seen,  missiles  within  the  joint  are 
first  removed,  the  synovial  cavity  is  closed,  and  the 
fracture  treated  independently  as  though  it  were  the 
only  lesion.  Sencert  has  described  a  remarkable  in- 
stance of  complete  success. 

After  an  operation  conducted  with  the  intention  of 
leaving  nothing  unexplored,  the  subsequent  course  of 
the  case  is  constantly  uneventful  and  aseptic  ;    the 
dressing  may  be  left  untouched  for  ten,  twelve,  or 
fifteen  days,  and  when  it  is  removed,  the  wounds  are 
found  to  be  of  a  fine  bright  red  colour.    From  this  point 
onwards,  if  time  is  available  for  dressing  the  case  daily, 
the  wound  may  be  left  exposed  to  the  air  for  some 
hours  each  day,  and  healing  will  be  accelerated  ;    if 
the  time  cannot  be  spared,  dressing  at  long  intervals 
is  continued.     With  this  excellent  method  I  have  seen 
union  occur  in  fractures  by  the  fourth  dressing.     Gener- 
ally the  patient  will  be  able  to  lift  his  limb  from  the 
immobilisation  apparatus   between  the  fortieth   and 
forty-fifth  days.     It  will,  however,  be  prudent  not  to 
allow  him  to  walk  alone  until  a  hundred  days  have 
elapsed,  in  order  to  avoid  the  disappointment  of  bend- 
ing the  callus  ;    active  movements  of  the  knee  may, 
however,  be  begun  early,  and  when  the  patient  is  finally 
allowed  to  get  up,  walking  will  be  easy,  the  stage  of 
crutches  will  be  brief  ;  I  have  seen  patients  ready  for 
discharge  towards  the  one  hundred  and  twentieth  day. 
(6)   Fixation    and    continuous    extension. — (1)    The 
guiding   pi'inciples. — After    operative    disinfection    of 
the  fracture,  fixation  and  continuous  extension  constitute 
the  two  essential  objects  in  treating  all  fractures  of  the 
thigh.      Asepsis  demands  good  fixation ;  without  the 
latter,  continuous  trauma  infects  different  parts  of  the 
wound  and  increases  the  virulence  of  the  organisms 
present,     Continuous  extension  is  the  only  means  of 
restoring  bone  and  muscle  to  normal  positions,  that  is 
of  reducing  the  fracture,  which  in  its  turn  is  the  best 
way  of  ensuring  immediate  satisfactory  progress,  and 


518  TREATMENT    OF    FRACTURES 

at  the  same  time  of  safeguarding  the  future  function 
of  the  limb. 

How  should  these  two  necessary  conditions  of  treat- 
ment be  realised  ? 

Three  principles  should  always  underlie  it  : — 

(i)  An  immobilisation  of  the  femur  is  not  satisfatiory 
unless  the  appliance  is  fixed  to  the  pelvis,  or  buttressed 
against  the  projections  of  the  latter,  thereby  uniting  it 
with  the  femur. 

All  the  trough  splints  at  present  in  use  are  thoroughly 
bad  appliances  for  fixation,  and  their  use  should  be 
permanently  discontinued. 

(ii)  Continuous  extension  is  only  satisfactory  when  the 
pull  is  exerted  in  the  axis  of  the  upper  fraginent. 

The  displacement  of  the  upper  fragnient  should  be 
studied  in  each  case,  and  the  extension  adapted  to  it ; 
when  these  various  displacements  are  considered  (see 
p.  508),  it  will  be  understood  that  there  are  fractures 
in  which  the  pull  should  be  exerted  in  abduction  (high 
fractures),  and  others  in  flexion  on  the  pelvis  (fractures 
of  thfe  middle  third).  There  can  therefore  be  no 
universal  apparatus. 

(iii)  To  avoid  useless  effort  and  facilitate  extension, 
the  limb  should  always  be  placed  in  a  positio7i  which 
naturally  neutralises  the  displacifig  force  :  the  ideal 
realisation  of  this  object  is  always  to  arrange  the  lower 
limb  with  the  leg  slightly  flexed  on  the  thigh,  and 
the  thigh  on  the  pelvis.  In  this  relaxed  position,  a 
much  smaller  force  will  effect  a  more  rapid  and 
complete  reduction. 

These  are  the  general  principles  on  which  the  treat- 
ment of  fractures  of  the  thigh  should  be  directed.  It 
is  by  reference  to  them  that  the  innumerable  appliances 
suggested  for  this  purpose  should  be  judged,,  and 
above  all,  it  is  by  such  reference  that  one  should  be 
chosen  for  any  particular  case.  This  book  is  not  a 
general  review  of  the  subject,  and  I  shall  only  describe 
my   own   idea   of   conducting   the   treatment   in   the 


FRACTURES    OF    THE   FEMUR         519 

successive  stages  of  the  case,  for  there  is  no  universal 
method  of  fixation  and  extension  applicable  every- 
where ;  at  each  echelon  of  the  Army  Medical  Service 
the  appliance  used  should  be  different  and  adapted  to 
local  conditions.  It  is  only  in  a  base  hospital  where 
treatment  will  be  continued  until  cure  is  effected  that 
the  ideal  appliance  can  be  realised. 

(2)  The  appliances  used  in  the  various  Echelons. — ■ 
(i)  At  the  Aid-post. — ^Temporary  fixation  should  be 
effected  by  applying  a  long,  well-padded  wooden  splint, 
from  the  iliac  crest  down  the  outside  of  the  limb.  This 
is  fixed  above  by  a  spica  bandage  to  the  pelvis,  and 
also  by  separate  bandages  to  the  knee  and  leg  ;    a 


^ 


Fig.  110. — Blake's  splint. 

second  splint  is  applied  on  the  inner  side.  This  rough 
method  is  far  superior  to  the  metal  trough  which  is 
no  more  than  a  makeshift. 

As  a  matter  of  fact,  the  ideal  arrangement  is  the 
splint  recommended  by  Blake.  It  is  very  light,  con- 
sisting of  two  iron  rods  {\  inch  in  diameter)  united  by 
an  oblique  curved  bar,  which  takes  its  purchase  beneath 
the  ischium.  It  can  easily  be  slipped  beneath  the  limb, 
which  is  slung  in  it  by  strips  of  bandage  ;  an  adjustable 
foot-rest  connecting  the  lower  ends  of  the  side-rods 
renders  it  adaptable  to  all  cases. 

(ii)  At  the  Clearing -statio7i . — After  operation,  a  con- 
tinuous extension  appliance  should  be  chosen,  which  is 
not  cumbrous,  does  not  interfere  with  the  personal 
hygiene  of  the  patient,  permits  ready  supervision  of 
the  limb,  and  can  be  quickly  applied.  It  is  also  import- 
ant that  it  should  be  possible  to  keep  a  stock  of  these. 


520  TREATMENT    OF    FRACTURES 

If  we  imagine  the  working  conditions  to  be  those  of 
an  active  ambulance  unit,  which  is  obliged  to  evacuate 
operation  cases  as  soon  as  they  can  be  moved,  and  not 
of  a  unit  in  a  quiet  sector,  which  keeps  its  cases  until 
they  are  cured — acting,  in  fact,  like  a  base  hospital — 
three  types  of  appliance  are  to  be  recommended : 
Sencert's  appliance,  Blake's  splint  rest,  and  the 
apparatus  of  Hey  Groves.* 

I  do  not  include  Pierre  Delbet's  apparatus  in  this 
list ;  it  is  adapted  only  for  use  at  the  base,  and  cannot 
be  used  in  a  busy  ambulance,  because,  being  difficult 
to  apply,  it  requires  time  and  careful  attention.  More- 
over, the  fact  that  it  permits  walking  is  of  no  advantage 
at  this  stage  ;  for  the  fractures  under  consideration, 
walking  appliances  should  be  reserved  for  convalescent 
cases  at  the  base. 

It  may  happen  that  a  unit  possesses  no  continuous 
extension  appliance  ;  plaster  of  Paris  is  then  the  only 
resource.  I  shall  describe  the  plaster  appliance  which 
seems  to  me  best  adapted  to  the  circumstances. 

(a)  Sencerfs  appliance  (fig.  Ill)  consists  of  a  sor£ 
of  Hennequin's  splint  made  by  cutting  to  the  right 
length  one  of  those  perforated  metal  sheets  supplied 
to  all  ambulances.  To  the  sides  of  this  are  nailed 
two  wooden  slats,  the  outer  being  40  to  44  inches  in 
Jcngth,  the  inner  32  to  34  inches  and  both  1  inch  wide 
and  i  to  f  inch  thick.  The  distal  ends  of  these  two 
slats  are  connected  by  a  thin  wooden  cross-bar,  and 
by  a  small  rigid  iron  wire  passing  through  the  hole  of 
a  cotton  reel ;  in  the  centre  of  the  appliance  another 
wooden  bar  is  fixed  transversely  by  screws  which  may 
easily  be  removed.  A  screw  hook  is  fixed  in  this  bar, 
carrying  a  wire  triangle,  through  which  passes  a  wide 
ring  of  rubber.  The  latter  is  simply  a  circular  segment, 
2  inches  in  width,  of  an  old  inner  tube.     Lastly,  two 

*  Schiassi,  of  Bologna,  describes  an  excellent  appliance,  in 
several  ways  resembling  that  of  Alquier,  which  deserves  to  become 
known  ;   it  is  very  neat,  and  may  be  used  during  transport. 


FRACTURES    OF    THE    FEMUR 


^^\ 


vertical  pieces  of  wood,  7  to  8  inches  in  length,  form  a 
support  for  the  appliance  and  are  fixed  at  the  lower 
end  of  the  metal  trough. 

The  following  is  the  procedure  for  applying  the 
a2)paratus:  In  the  metal  splint  is  placed  a  towel,  and 
a  quantity  of  cotton  wool,  in  order  to  pad  it  well. 
After  esquillectomy  and  dressing,  the  foot  and  leg  are 
firmly  bandaged  up  to  the  position  of  the  dressing  on 
the  thigh.  Immediately  above  the  knee  is  placed  a 
Hennequin's  sling,  through  which  the  pull  is  to  be 
exerted.     The  middle  bar  of  the  splint  with  its  rubber 


Fig.   111. — Sencert's  appliance,  which  effects  continuous 
extension  and  allows  of  transport. 

ring  is  unscrewed,  and  the  thigh  is  placed  in  the  splint, 
the  inner  border  of  which  should  be  brought  up  as 
close  as  possible  to  the  ischio-pubic  ramus,  which  brings 
the  outer  border  up  as  far  as  the  anterior  superior  iliac 
spine.  The  middle  bar  is  then  screwed  m  position. 
A  cord  fixed  to  the  loop  of  the  Hennequin  sling  passes 
over  the  reel  acting  as  a  pulley,  and  is  fixed  to  the 
india-rubber  ring,  which  is  previously  stretched : 
continuous  traction  is  thus  effected.  Finally,  a  small 
wooden  splint  is  applied  to  the  anterior  aspect  of  the 
thigh,  which  is  intended  to  prevent  antero-posterior 
displacement,  and  the  towel  originally  placed  in  the 
trough  is  folded  over  the  dressing.  Three  straps  are 
used  to  kee23  the  whole  in  position. 

This    appliance    effects    perfect    extension,    easily 
reducing  the  greatest  displacements ;    further,  it  pro- 


522 


TREATMENT    OF    FRACTURES 


duces  very  effective  immobilisation,  and  is  satisfactory 
for  long-distance  trans j)ort.  I  have  used  it,  and 
obtained  excellent  results.  It  has  only  one  disadvant- 
age :  it  cannot  reduce  the  anterior  displacement  in 
fractures  in  which  the  upper  fragment  is  directed  for- 
wards. In  these  cases  an  appliance  is  required  which 
flexes  the  thigh  on  the  pelvis.  Ihe  surgeon  may  be 
satisfied  with  provisionally  exercising  direct  pressure 
by  a  small  wooden  splint,  as  suggested  by  Sencert,  but 
this  should  only  be  temporary  ;  better  results  can  be 
obtained  with  other  appliances. 

(yS)  Blake's  splint,  described  above  (fig.  110),  is  much 
to  be  recommended  :  it  is  convenient  in  use  and  the 
reverse  of  cumbersome,  easy  to  apply,  and  an  ideal 
appliance  for  ambulance  work. 

When  it  is  applied  to  the  limb,  the  latter  may  easily 
be  suspended  from  the  roof  of  an  ambulance  car  by 
cords  and  a  spring  ;  it  thus  constitutes  a  treatment 
and  a  transport  appliance  at  the  same  time. 


Fig.   112. — G.  W.  Hawley's  continuous  extension  apparatus. 


It  may  be  modified  to  resemble  G.  W.  Hawley's 
appliance,  shown  in  fig.  112,  which  appears  equally 
excellent. 


FRACTURES    OF    THE    FEMUR 


52:3 


(7)  Hey  Groves's  splint  (fig.  113)  is  purely  an  ap- 
pliance for  treatment,  but  its  convenience  and  real 
advantages  should  bring  it  into  general  use  in  surgical 
ambulances.  Its  object  is.  to  effect  immobilisation  by 
suspension  with  continuous  extension  by  simple  means, 
thus  obviating  the  use  of  the  cumbrous  suspension 
appliances  which  render  immobilisation  by  suspension 
difficult  at  the  front. 

By  means  of  steel  rods,  |  inch  in  section,  two  inclined 
planes  of  unequal  length  are  constructed.     The  ex- 


FiG.   113, — The  Hey  Groves  apparatus. 


tremities  of  the  two  rods  are  bent  back  and'  fixed  to 
a  steel  frame. 

A  transverse  metal  plate  ensures  rigidity  and  serves 
as  a  fixation  point  for  the  vertical  branches  of  the 
extension  support.  The  suspension  sling  is  made  as 
usual  with  flannel  bands.  Hey  Groves  also  recom- 
mends strips  of  rubber  (pneumatic  tyre  inner  tube) 
in  the  parts  opposite  the  w^ounds,  their  elasticity  acting 
as  a  counter-extension.  The  sling  is  padded,  and  the 
limb  placed  in  it,  with  the  knee  opposite  the  angle 
between  the  two  inclined  planes,  both  knee  and  hip- 
joints  being  flexed  ;  extension  is  applied  above  the 
knee  in  the  usual  way,  the  traction  cord  passing  over 
a  pulley  (fig.  113).  Steady  traction  on  the  thigh  should 
be  maintained  while  the  appliance  is  being  fitted. 


524  TREATMENT    OF    FRACTURES 

This  appliance  has  numerous  advantages  :  it  is  not 
cumbersome  ;  an  ambulJance  unit  can  keep  a  large 
stock  of  them,  the  frames  fitting  one  into  the  other  ; 
they  are  easily  cleaned,  even  sterilised  ;  they  rapidly 
exert  continuous  extension  in  flexion,  which  is  ideal 
in  the  majority  of  cases,  counter-extension  being 
effected  by  the  weight  of  the  limb  ;  dressing  and  X-ray 
examination  is  easy,  and  painless  transport  is  possible. 

(8)  Plaster  appliances. — All  kinds  of  circumstances 
necessitate  the  use  of  plaster,  hut  a  plaster  appliance 
should  never  be  anything  but  temporary,  to  be  replaced 
as  soon  as  possible  by  a  continuous  extension  appliance, 
leaving  the  limb  freely  exposed  to  the  air.  Un- 
doubtedly, numerous  forms  of  plaster  appliance  have 
been  suggested,  which  effect  continuous  extension  by 
means  of  lacing,  or  of  shafts  and  springs  resembling 
those  in  Delbet's  appliance,  but  these  are  only  mediocre 
appliances,  whose  application  occupies  a  great  deal  of 
time,  and  whose  therapeutic  effect  is  decidedly  inade- 
quate, because  within  a  short  time  their  immobili- 
sation is  no  longer  good,  because  they  imprison  the 
tissues,  and  because  they  do  not  afford  the  choice  of 
a  good  position  for  traction.  I  need  not  emphasise 
this  last  disadvantage  after  what  I  have  written 
above  on  the  point. 

Granted  that  they  cannot  be  used  for  treatment, 
plaster  appliances  should  be  as  simple  as  possible  : 
their  sole  object  is  to  afford  a  good  fixation  until  the 
apparatus  best  suited  to  the  case  can  be  applied  ;  for 
this  purpose  the  best  plaster  is  the  dorsal  pelvi-pedial 
rest,  described  in  Part  I,  p.  195  >  for  post-operative 
immobilisation  after  resection  of  the  hip  (see  figs.  62 
and63,  rartl). 

It  consists  of  two  plastered  portions  forming  a  T 
with  unequal  branches  :  the  pelvic  limb  covers  the 
antero-lateral  part  of  the  pelvis,  being  applied  over  the 
iliac  crests  and  the  hips  ;  the  other  is  moulded  as  a 
trough  on  the  anterior  aspect  of  the  thigh,  leg,  and  foot. 


FRACTURES    OF    THE    FEMUR       5^5 

and  the  limb  is  as  it  were  suspended  by  a  roller  bandage 
fixing  it. 

Bosquette  has  very  successfully  modified  this  splint 
by  maintaining  rigidity  in  the  region  of  the  thigh 
simply  by  two  strips  of  sheet  iron,  with  the  result 
that  the  wounded  region  is  freely  exposed,  being  merely 
crossed  by  these  narrow  connections,  which  do  not 
interfere  with  dressing,  and,  being  reinforced,  are  very 
resistant.     The  diagram  below  (fig.   114)  shows  the 


Fig.  114. — Dorsal  pelvi-pedial  plaster  support,  with  reinforcing 
sheet-iron  slats  (Bosquette's  model),  (a)  Distance  from  the  pubis 
to  the  xiphoid  cartilage  ;  (b)  Semi-circumference  of  the  trunk  at 
the  level  of  the  umbilicus,  increased  by  8  in.  ;  (c)  Length  of  thigh 
occupied  by  the  dressing;  (d)  Semi-circumference  of  the  ]imb  ; 
(e)  Total  length,  from  the  level  of  the  xiphoid  cartilage  to  the  base 
of  the  toes,  following  the  curvatures  of  the  limb.  The  appliance 
consists  of  twenty  thicknesses  of  tarlatan,  and  the  reinforcing  slips 
ten  thicknesses ;  the  dotted  lines  indicate  the  seams.  Only  one  con- 
necting slat  is  shown,  and  the  reinforcing  support.  The  apparatus 
usually  consists  of  two  slats  and  three  supports, 

exact  construction.  I  have  several  times  received 
cases  immobilised  in  this  way  :  they  had  had  no  pain 
during  transport,  and  the  fragments  were  kept  rigidly 
in  position,  without,  however,  being  completely  reduced. 
This  easily  constructed  apparatus  seems  to  me  the  best 
existing  type  of  plaster  appliance  for  the  first  few  days, 
and  for  transport. 

(3)  For  transport,  no  form  of  trough  should  be  used ; 
they  are  painful,  and  the  injury  is  increased  by  con- 
tinuous trauma  :  their  supply  to  the  Medical  Service 


526 


TREATMENT    OF    FRACTURES 


should  be  stopped.  In  place  of  them,  one  of  the 
followmg  may  be  used  :  Sencert's  appliance,  Blake's 
splint,  or  Bosquette's  type  of  the  dorsal  pelvi-pedial 
plaster. 

(4)  At  the  base  hospital,  after  dressing,  X-ray 
examination,  and  slight  further  operation  if  necessary, 
when    the    direction    of    the    displacement    has    been 


Fig.   115. — Susjjension  apparatus  for  fracture  of  the  thigh,  much 
simplified  and  easily  improvised. 


determined,  the  final  apparatus  should  be  applied  as 
soon  as  possible. 

Three  can  be  recommended  :  a  suspension  appli- 
ance, Pierre  Delbet's  apparatus,  andAlquier's  appliance. 

/  consider  the  suspension  apjiliance  to  he  the  best  of 
these  : 

Because  it  allows  of  continuous  extension  in  any 
position  whatever,  according  to  the  requirements  of 
each  individual  case. 

Because  it  does  not  jDrevent  careful  supervision  of 
the  wounds  and  of  the  entire  limb. 

Because  it  allows  oi  the  maximum  possible  exposure 


FRACTURES    OF    THE    FEMUR        527 

to  the  air  or  the  sun,  and  does  not  closely  confine  the 
muscles  and  joints. 

Because  it  greatly  facilitates  personal  hygiene  in  that 
it  is  possible  for  the  patient  to  move  and  lift  himself 
with  ease  and  without  pain. 

(I)  Suspension  appliance  with  continuous  extension. 
— (i)  The  Appliance. — This  is  the  Balkan  apparatus 


Fig.   116. — Frame  for  suspension  splint. 

still  referred  to  as  American,  although  its  principle 
is  apparently  French.     It  comprises  : 

A  frame  of  the  type  described  on  p.  500  and  shown 
in  fig.  38,  or  the  overhead  bar  (fig.  115),  which  is  very 
satisfactory  in  use. 

A  frame  fitted  as  a  sling  with  bands  of  linen.     I 


Fig.   117. — A  very  simple  model  of  the  metal  splint  necessary  for 
the  construction  of  a  suspension  hammock  ;   this  model  is  the  best. 

have  used  many  kinds  of  frames  :  one  of  deal  with  a 
support  curved  like  the  back  of  an  arm-chair  for  the 
pelvic  part   (this  is   the   simplest   model,  and  easily 


528  TREATMENT    OF    FRACTURES 

improvised  anywhere);  a  metal  frame  constructed 
on  the  type  of  Blake's,  the  outer  border  extending  from 
the  anterior  superior  iliac  spine  to  2|  inches  beyond  the 
heel,  and  the  inner  border  from  the  pubes  to  2|  inches 
beyond  the  heel,  6  inches  wide  at  the  foot,  and  14  inches 
wide  at  the  groin  (fig.  110);  the  frame  used  by  Tuffier, 
the  form  of  which  is  shown  in  fig  116;  the  double 
metal  splint  shown  in  fig.  117  and  also  in  fig  105. 
All  of  these  have  given  me  the  same  good  results,  but 
the  last  of  the  models  shown  is  certainly  the  most 
practical,  on  account  of  the  two  connecting  arches, 
which  can  be  used,  the  lower  for  fixing  the  foot,  and 
the  upper  for  drawing  the  appliance  backwards, 
maintaining  its  position,  and  preventing  slipping. 

When  possible,  however,  a  jointed  splint  should  be 
used,  as  shown  in  fig.  118.  This  allows  of  flexion  of 
the  leg  on  the  thigh  *  ;  a  screw  joint  and  curved  guides 
on  each  side  make  it  possible  for  the  leg  to  be  placed 
in  any  degree  of  flexion  desired. 

The  suspension  sling  is  completed  by  strips  of 
bandage  ;  at  the  level  of  the  wound  this  material 
is  replaced  by  a  double  sterile  towel,  one  enveloping 
the  dressing,  and  the  other  acting  as  a  sling.  The  four 
hooks  are  intended  for  suspension  of  the  apparatus  in 
the  usual  arrangement  (fig.  115). 

The  weight  necessary  for  counterpoising  a  thigh 
varies  from  4  to  5  kilogrammes,  according  to  the  weight 
of  the  limb  and  the  amount  of  friction  in  the  pulleys. 

(ii)  Continuous  extension. — I  have  always  em})loyed 
traction  by  bands  of  strapping,  applied  as  in  the 
classical  type  of  extension  (Tillaux).  If  this  is  to  be 
well  tolerated,  the  limb  must  first  be  shaved  and 
washed  with  ether  ;    the  crural  extremities  of  the  two 

*  Soubbotitch  recently  described  an  ingenious  and  simple  appli- 
ance facilitating  treatment  in  the  flexed  position  {Academie  de 
Medecine,  Oct.  24th,  1916).  The  original  feature  of  his  metal  rest 
is  a  joint  which  allows  automatic  lengthening  of  the  femoral  inclined 
plane  between  the  tuberosity  of  the  ischium  and  the  popliteal  space, 
thus  adapting  itself  to  the  increased  length  of  the  thigh  in  extension. 


FRACTURES    OF    THE    FEMUR        529 

parallel  bands  must  be  divided  into  strips,  which  cross 
each  other  ;  instead  of  using  circular  strips  of  strapping 
to  fix  the  parallel  bands  in  position,  a  spiral  strip  should 
be  applied  from  the  malleoli  to  above  the  knee. 

If  the  pull  is  to  be  exerted  with  the  limb  flexed,  the 
imbrication  on  the  thigh  should  be  very  precise,  and 
a  few  circular  bands  will  be  necessary  for  fixation  ;  the 
lowest  of  these  should  be  sufficiently  far  from   the 


Fig.  118. — Jointed  splint  permitting  treatment  by  flexion  at 
the  knee  and  hip  joints.  When  the  patient  represented  here  was 
l^ng  down,  the  thigh  was  flexed  to  45°  on  the  pelvis. 

patella  not  to  come  in  contact  with  it,  as  this  is  very 
painful.  As  the  weight  required  for  extension  is  much 
greater  in  flexion  than  in  extension,  traction  may  also 
be  exerted  through  bands  of  strapping  placed  over  a 
dressing  surrounding  the  knee. 

Certain  patients  do  not  tolerate  traction  well  ;  the 
bands  take  the  skin  off,  and  in  a  short  time  cannot  be 
endured;  under  these  conditions,  the  Finochietto 
stirrup  as  employed  by  Chutro  *  appears  very  suitable 

*  Heitz  Boyer  has  recently  modified  it  by  the  addition  of  a 
flanged  ahiminium  foot-piece  and  a  transverse  spring,  which  ensures 
a  good  position  of  the  foot  in  flexion  or  extension  on  the  leg  under 
all  circumstances  {Societe  de  Chirurgie,  October  2oth,    1916). 


530 


TREATMENT    OF    FRACTURES 


(see  fig.  33),  if  the  pull  is  to  be  exerted  in  extension. 
I    have   no    personal   ex- 
perience of  it. 

(iii)  Choice  of  'position  for 


Fig.  119. — Double  fracture  of 
the  tliigh,  seriously  infected, 
treated  at  the  front  by  simple 
drainage  of  the  soft  parts  ;  radio- 
graph on  arrival  tuider  my  care 
on  the  eighth  day.  My  first 
idea  was  to  amputate. 


Fig.  120. — Radiograph  one 
month  later  :  complete  sub- 
periosteal esquillectomy.  The 
periosteum  is  already  very  ap- 
parent ;  continuous  extension 
has  brought  the  lower  fragments 
well  downwards,  but  reduction 
is  not,  liowever,  sufficient,  as 
the  upper  fragment  is  projecting 
forwards. 


extension. — -This  is    decided  by   clinical    examination 


FMACTURES    OF    THE    FEMUR        531 

and  radiographs  taken  from  both  aspects.    In  a  general 
way,  traction  with  the  limb  flexed  on  the  pelvis  (30°) 


Fig.  121. — ^Third  radiograph, 
one  month  after  the  former. 
The  limb  has  been  placed  in  a 
suspension  appliance,  in  an  al- 
most vertical  position,  at  first 
in  line  with  the  trunk,  then  in 
abduction.  The  anterior  dis- 
placement of  the  upper  fragment 
was  thus  almost  completely  cor- 
rected, and  the  intermediate 
fragment  carried  outwards,  but 
abduction  has  had  an  unfor- 
tunate effect  on  the  upper  frag- 
ment. 


Fig.  122. — Fourth  radiograph 
at  the  end  of  the  fourth  month, 
traction  of  7  kilos  having  been 
applied,  in  line  with  the  trunk, 
and  with  flexion  to  45°,  in  a 
suspension  appliance.  The  re- 
duction is  now  very  satisfactory. 


in  marked  abduction  (45°  to   50°)  is  suitable  in  frac- 
tures of  the  upper  part  of  the  bone  ;   in  fractures  of 


532  TREATMENT    OF    FRACTURES 

the  middle,  traction  with  the  knee  extended,  but  with 
more  or  less  pronounced  flexion  of  the  thigh  on  the 
pelvis  (30°  to  80°)  ;  in  fractures  of  the  lower  part, 
traction  with  slight  flexion  of  the  thigh,  and  flexion  of 
the  leg  to  about  30°. 

But  there  is  an  optimum,position  for  each  individual 
case  ;  slight  abduction  is  often  necessary  for  fractures 
of  the  middle  part  of  the  bone,  or  slight  flexion  of  the 
leg  to  counteract  the  backward  rotation  of  the  lower 
fragment ;  sometimes  it  is  necessary  to  place  the 
thigh  almost  at  a  right  angle  to  the  trunk.  In  a  case, 
radiographs  of  which  are  reproduced  (figs.  119,  120, 121, 
and  122),  I  was  obliged  to  alter  the  position  of  the 
thigh  several  times  to  effect  reduction  :  traction  was 
first  applied  with  the  thigh  flexed  to  85°  on  the  pelvis, 
in  order  to  correct  a  forward  projection  of  the  upper 
fragment ;  then  it  was  applied  in  adduction  with  the 
object  of  bringing  the  intermediate  fragment  into 
line  ;  finally,  the  limb  was  brought  straight  again.  The 
radiographs  show  the  successive  stages  of  this  treatment 
and  the  result  obtained.  These  successive  and  neces- 
sary stages  would  have  been  impossible  with  any 
ordinary  appliance. 

(iv)  Fitting  the  apparatus. — When  placing  the  limb 
in  the  splint,  an  assistant  should  make  firm  traction 
on  the  thigh  and  the  leg,  so  that  pain  may  be  avoided 
and  nothing  may  move  in  the  region  of  the  fracture, 
which  is  further  supported  by  two  hands  beneath  it. 
The  splint  is  j^repared  beforehand  and  is  slipped  under 
the  limb  and  passed  as  far  upwards  as  possible  so  that 
it  takes  purchase  from  the  pelvis  :  this  is  essential. 

Traction  is  immediately  made  by  the  weight  esti- 
mated to  be  necessary  ;  a  weight  of  3  kilogrammes  is 
used  at  first,  and  increased  each  day  by  500  grammes, 
until  7  to  8  kilogrammes  is  being  used  :  this  extending 
force  will  generally  effect  axial  reduction.  If  a  double 
inclined  plane  is  used,  4  kilogrammes  is  often  sufficient. 

The  suspension  cords  are  then  fixed  to  the  hooks, 


FRACTURES    OF    THE    FEMUR        533 

and  the  counterpoising  weight  placed  in  position  :  this 
should  be  about  4  to  5  kilogrammes  ;  the  weight  must 
be  sufficient  to  suspend  the  splint  and  the  limb  just 
off  the  bed,  with  the  limb  slightly  flexed  on  the  pelvis. 
If  there  is  pain,  the  weight  is  increased  and  the  position 
of  the  median  pulley  on  the  cord  shifted  until  a  painless 
equilibrium  is  obtained,  and  then  the  position  of  the 
traction  pulley  should  be  finally  fixed.  The  steps  of 
the  procedure  cannot  be  definitely  described  ;  only  one 
rule  can  be  given  :  in  proportion  as  the  patient  suffers, 
the  position  is  bad.  When  the  appliance  is  in  good 
equilibrium,  all  movements  of  the  limb  as  a  whole 
are  possible  and  not  painful. 

The  sterilised  sheets  are  then  applied  beneath  the 
splint,  and  the  whole  apparatus  is  enveloped  in  a  small 
covering  of  sterilised  wool,  in  order  to  keep  the  limb 
warm.  A  small  pad  of  cotton  wool  may  also  be  placed 
between  two  layers  of  gauze  and  the  foot  covered 
with  it. 

As  is  always  the  case  when  the  lower  limb  is  immobi- 
lised, the  mattress  should  be  firm,  and  made  resistant 
by  slipping  fracture  boards  beneath  it :  this  is  the 
classical  procedure. 

(v)  Care  of  the  foot. — ^The  position  of  the  foot  should 
be  examined  every  day  in  order  to  prevent  the 
development  of  a  troublesome  pes  equinus.  The 
patient  should  be  advised  to  practise  frequent  move- 
ments of  flexion  and  extension,  in  order  to  avoid  stiff- 
ness of  the  tibio-tarsal  joint.  For  greater  safety,  if 
necessary,  the  foot  should  be  kept  at  right  angles  by 
means  of  a  flannel  bandage  fastened  to  the  lower  curved 
metal  arch  of  the  splint,  or  by  means  of  a  small  paste- 
board or  aluminium  foot-piece  attached  to  the  sole. 

(vi)  Method  of  dressing. — In  fractures  in  which  the 
operation  has  been  performed  at  an  early  stage,  and 
subsequently  remains  clinically  aseptic,  dressing  at 
long  intervals  is  an  excellent  thing.  If  the  wounds 
suppurate,  I  expose  them  each  day  to  the  air,  if  not 


534 


TREATMENT   OF   FRACTURES 


to  the  sun.  For  this  purpose,  or  at  least  for  dressing, 
the  counterpoise  weight  is  pulled  down  in  order  to 
raise  the  limb  higher  above  the  bed,  the  slings  of  the 
splint  corresponding  to  the  wound  are  unfastened,  the 
dressing  is  removed,  and  a  sterile  towel  is  immediately 
folded  and  placed  beneath  the  thigh,  with  its  edges 
folded  over  the  metal  frame  of  the  splint.  Dressing 
is   usually   very   simple   after   esquillectomy.      Figs. 


Fig.  123.. 


1 23,  124,  and  125  are  the  best  description  of  the  suitable 
way  of  performing  it. 

(vii)  Possible  complications. — Apart  from  the  trouble 
sometimes  caused  by  the  continuous  extension  bands, 
which  offers  much  scope  for  the  personal  ingenuity  of 
nurses,  I  know  of  only  two  possible  complications — 
oedema  of  the  leg  and  foot  when  traction  is  exerted 
with  the  knee  flexed,  and  cedematous  swelling  of  the 
lips  of  the  wound. 


FRACTURES    OF    THE    FEMUR 


h.U) 


(Edema  of  the  leg  is  due  to  venous  compression  in 
the  popliteal  space  ;  it  can  be  made  to  disappear  by 
altering  the  angle  of  flexion,  removing  the  garter 
suspension  band,  or  exerting  the  pull  for  some  time 
with  the  knee  extended. 

An  Cfidematous  condition  of  the  wound  is  the  first 
sign  of  a  slight  deep  infection,  due  sometimes  to 
negligence  in  dressing,  but  almost  always  preliminary 


Fig.  124. 


to  the  elimination  of  a  sequestrum.  Sometimes,  but 
only  after  esquillectomy  performed  during  the  febrile 
state  (it  happens,  in  fact,  towards  the  end  of  the 
second  month),  one  of  the  extremities  of  the  shaft 
becomes  necrosed ;  a  radiograph  and  exploration  of  the 
wound  with  forceps  will  detect  the  sequestrum  and 
succeed  easily  in  clearing  up  this  slight  complication. 
If  necessary,  the  patient  may  be  anaesthetised  with 


536 


TREATMENT   OF   FRACTURES 


ethyl-chloride,  and  the  cause  of  the  trouble  investigated 
in  any  suitable  way. 

(viii)  Duration  of  Unmdbilisation. — The  progress  of  the 
fracture  should  be  followed  by  radiographs.  Unfortu- 
nately the  suspension  apparatus  cannot  be  transferred 
with  the  patient  to  the  X-ray  room,  but  the  extension 
may  be  easily  removed,  the  suspension  cords  detached, 
and  the  limb  carried  in  the  splint. 

As  a  rule,  periosteal  proliferation  is  visible  in  a  good 


Fig.  125. 

X-ray  plate  in  the  form  of  a  more  or  less  obvious 
shadow  at  the  end  of  three  weeks.  At  this  stage  the 
deep  surface  of  the  wound  is  granulating,  and  of  a 
bright  red  colour,  and  is  firm  and  regular  to  the  touch. 
At  the  end  of  six  weeks  the  ossification  is  clearly 
outlined  in  the  radiograph,  usually  on  the  side  opposite 
to  that  of  the  surgical  wound.  Some  patients  are  able, 
from  this  point  onwards,  to  support  the  limb  if  it  is 
lifted,  but  without  always  being  able  to  raise  the  heel 
from  the  bed  unaided.  Subsequently  the  union  be- 
comes definite,  and  usually  towards  the  end  of  the 


FRACTURES   OF    THE   FEMUR       537 


second  month,  when  healing  is  complete  the  clinical 
impression  is  that  of  a  firm  callus. 

In  young  subjects,   continuous  extension   may  be 
permanently  discontinued  at  this  point.     In  the  case 
of  older  men,  it  is  wise  to  continue  it  for  a  few  weeks 
(until   the    hun- 
dredth   day)    in 
order    to    avoid 
secondary  curva- 
ture. 

Owing  to  the 
necessity  for  pro- 
longed extension, 
it  would  seem 
advisable  to  use 
D  e  1  b  e  t '  s  ap- 
pliance from  the 
third  month  on- 
wards. 

(2)  Delbefs  ap- 
pliance. —  The 
object  of  this  ap- 
paratus is  to 
allow  the  patient 
to  leave  his  bed 
and  walk  at  an 
early  stage.  It 
consists  of  a 
metal  pelvic  ring 

specially  curved  which  takes  purchase  against  the 
ischium  and  the  ischio-pubic  ramus,  and  three  spring 
extension  shafts  fixed  below  to  a  plaster  collar  moulded 
round  the  condyles.  Of  these  three  shafts,  one  is 
internal,  one  anterior,  and  the  third,  which  is  longer, 
ends  in  a  hollow  cylinder  supported  against  the  tro- 
chanter. 

The  accompanying  fig.  126  explains  the  construction 
of  the  appliance. 


Fig.  126. — Pierre  Delbet's  apparatus. 


538  TREATMENT    OF    FRACTURES 

The  following  are  required  for  fixing  it  in  position  : 
an  ordinary  plaster  bandage  2|  inches  wide  and  6  yards 
long,  and  a  band  consisting  of  twelve  thicknesses  of 
starched  tarlatan  3  fingers  in  width  and  a  yard  long. 
This  is  split  at  each  extremity  along  the  median  line 
and  almost  to  its  centre  ;  in  this  way  a  four-tailed 
band  is  produced,  which  is  intended  to  surround  the 
lower  part  of  the  metal  appliance  on  the  thigh. 

The  appliance  is  fitted  in  the  following  stages  : 

Construction  of  a  supra-condylar  plaster  ring,  grip- 
ping the  femoral  condyles. 

Padding  of  the  pelvic  ring. 

Placing  the  pelvic  ring  in  position,  the  supports, 
springs,  and  pins  having  been  removed,  but  with  the 
strap  attached.  It  is  placed  on  the  inner  side  of  the 
thigh,  with  its  concavity  facing  upwards  and  outwards. 
The  hand  is  slipped  under  the  thigh,  and,  by  means  of 
the  strap,  brings  the  posterior  part  of  the  ring  beneath 
the  thigh,  while  the  other  hand  applies  it  to  the  genito- 
crural  fold. 

Fitting  of  the  strap,  springs,  and  crutch- supports. 

Application  of  the  four-tailed  band  beneath,  the 
plaster  collar. 

Construction  of  a  Delbet  walking  leg-appliance  (see 
p.  564  ),  which  is  fastened  by  means  of  a  Scultet 
apparatus.* 

When  all  is  in  position,  time  is  allowed  for  the  plaster 
to  dry,  and  tension  of  the  springs  is  brought  into 
play,  the  internal  spring  being  powerfully  compressed, 
the  external  less,  and  the  anterior  very  little. 

During  the  following  days  the  tension  is  modified 
so  as  to  effect  a  progressive  reduction,  and  when 
this  has   been   obtained,   the  apparatus    is   fixed    in 

♦  Scultet's  apparatus  is  a  kind  of  many- tailed  bandage,  the  ends 
of  which  are  rolled  round  a  cane  on  each  side.  The  tails  are  brought 
together  round  the  limb  over  the  plaster  in  order  to  mould  the 
latter  to  the  contour  of  the  limb  and  the  apparatus  is  subsequently 
removed.  For  further  particulars  see  Delbet,  Le  Traitement  des 
Fractures.     (Paris,  1916,  p.  90.) — Editob. 


FRACTURES   OF    THE   FEMUR       5.39 

position  with  split  pins,  and  the  patient  allowed  to 
get  up. 

The  degree  of  tension  of  the  springs  and  the  condition 
of  the  skin  in  the  genito-crural  region  require  frequent 
attention. 

At  the  end  of  about  fifty  days  the  leg-plaster  may 
be  removed.  The  rest  of  the  appliance  is  kept  on  for 
at  least  two  months. 

This  appliance  has  great  advantages,  which  are 
recognised  by  all  who  have  used  it :  it  reduces  well, 
allows  the  patient  to  get  up  at  an  early  stage,  and 
ensures  a  good  ultimate  result.  It  possesses  the  dis- 
advantage of  being  diflficult  to  apply  well. 

I  believe  that  its  use  is  particularly  advisable  during 
the  period  of  convalescence,  which  it  shortens  con- 
siderably. I  have  only  employed  it  in  this  late  stage, 
and  have  no  experience  of  its  use  in  the  earlier  stages. 

(3)  Alquier's  appliance. — By  making  use  of  certain 
parts  of  Delbet's  appliance,  Alquier  has  constructed  an 


Fig.  127. — Alquier' s  apparatus. 

original  apparatus,  the  excellent  results  of  which  I  have 
seen  at  the  hospital  at  Chalons,  but  which  I  have  never 
actually  employed.  It  has  been  described  by  Foisy, 
whose  account  is  reproduced  here  : 

It  is  a  combination  of  a  mechanical  and  a  plaster 
apparatus.  The  mechanical  part  consists  of  five 
principal  pieces  :  an  upper  collar,  a  pedestal-support, 
two  lateral  bars,  and  a  traction  appliance. 


540  TREATMENT   OF    FRACTURES 

The  upper  collar  is  of  metal,  consisting  of  two  parts, 
an  internal  ischio-pubic  piece  curved  exactly  as  in 
Delbet's  appliance,  and  another,  external,  jointed  to 
the  former  behind,  and  also  attached  to  it  in  front  in 
the  region  of  Poupart's  ligament.  A  screw  unites  the 
two  pieces  firmly. 

The  semicircular  pedestal-support  has  a  large  flat 
base,  which  acts  as  a  support.  A  perforated  transverse 
bar  is  fitted  to  the  former,  through  which  passes  an 
extension  screw. 

The  lateral  bars  are  composed  of  four  pieces,  allowing 
adjustment  according  to  the  length  of  the  limb  and 
the  width  of  the  thigh.  The  inner  bar  is  fixed  at  one 
end  to  the  collar,  and  at  the  other  to  the  pedestal,  but 
the  upper  end  of  the  outer  bar  slides  in  the  collar, 
and  ends  in  a  crescentic  pad  which  can  be  adjusted 
vertically  and  transversely,  and  takes  purchase  against 
the  outer  surface  of  the  ilium  ;  its  lower  end  is  fixed  to 
the  pedestal.  The  two  lateral  bars  are  supported  about 
their  middle  by  an  extra  pedestal-rest. 

The  traction  appliance  consists  of  a  semicircular 
condylar  collar  ending  in  two  wings  sliding  on  the 
lateral  bars,  and  a  stirrup  sliding  in  the  same  way. 

The  leg,  knee,  and  popliteal  space  are  padded,  and  a 
plaster  apparatus  is  applied  consisting  of  a  collar 
moulded  on  the  condyles,  as  in  Delbet's  appliance,  and 
a  plaster  splinting  extending  from  the  lower  part  of 
the  condylar  collar  to  the  base  of  the  toes. 

In  fitting  the  apparatus,  the  upper  collar  is  first 
placed  in  position,*  and  the  limb  is  slung  between  the 
two  lateral  supports.  When  the  upper  collar  has  been 
secured,  the  external  pad  is  fixed  above  the  great 
trochanter,  the  collar  is  applied  closely  to  the  depression 
immediately  above  the  condyles,  and  fixed  there  by 
means  of  a  plaster  bandage.  Lastly,  a  stirrup  is  secured 
above  the  malleoli  by  means  of  another  plaster  bandage. 

*  Heitz  Boyer  has  recently  rendered  the  appliance  more  easily 
applicable,  by  making  the  external  support  movable. 


FRACTURES   OF    THE   FEMUR 


541 


When  the  plaster  is  dry,  traction  is  gently  and  pro- 
gressively applied  so  as  to  reduce  the  fracture  in  a 
few  days. 

6.  The  Treatment  of  cases  first  seen  at  a 
later  stage  or  after  previous  treatment — [a] 
A  case  is  progressing  well  after  several  days. — After 
radiography  and  study  of  the  displacement,  the  limb 
should  be  placed  under  continuous  extension  in  a 
suspension  apparatus.  Early  use 
of  Delbet's  appliance  is  aloo  pos- 
sible. 

Operation  is  obviously  unneces- 
sary. 

(b)  A  case  is  seen  with  pro- 
nounced local  sepsis. — ^Whether  the 
region  has  already  been  cleared  or 
not,  immediate  sub-periosteal  es- 
quillectomy  and  drainage  is  in- 
dicated. After  radiography,  a 
radical  operation  is  undertaken 
through  an  external  incision  :  the 
soft  parts  are  carefully  cleaned 
with  scissors,  and  a  minute  search 
is  made  for  free  splinters  em- 
bedded in  the  muscles.  When  the 
region  of  the  bone  is  reached,  ex- 
tensive esquillectomy  is  effected 
with  the  rugine.  /  am  more  and 
more  convinced  that  in  the  secondary  period,  sub- 
periosteal esquillectomy  should  be  complete,  bearing 
in  mind  the  vital  activity  of  the  periosteum  when 
irritated  by  the  infection  (see  figs.  24  and  25,  p329). 
The  medullary  canal  is  scraped,  gently  and  not  ex- 
cessively. Finally,  the  wound  is  packed  with  gauze 
moistened  in  hypertonic  saline,  and  the  limb  is  im- 
mediately placed  in  a  suspension  apparatus. 

The  dressing  should  be  rene^ved  in  forty-eight  hours. 
After  examination  of  the  wound,  and,  if  necessary, 


Fig.  128.  —  Bad 
comminuted  fracture 
with  nvunerous  shell- 
fragments  in  situ. 


542 


TREATMENT   OF   FRACTURES 


completion  of  the  mechanical  cleaning  by  excision  of 
any  torn  and  gangrenous  tissue,  a  fresh  dressing 
moistened  with  saline  is  applied. 

In  five  or  six  days  the  wound  will  generally  be  clean, 
the  temperature  normal,  and  the  course  of  the  case  will 
be  uneventful ;  dry  aseptic  dressings  may  then  be 
used. 

Elimination  of  a  sequestrum  from  the  ends  of  the 


Fig.  129. 


Fio.  130. 


Fig.  131. 


Fig.  129. — Radiograph  on  the  fifteenth  day'  after  total  sub- 
periosteal esquillectomy  (same  case  as  fig.  128). 

Fig.  130. — Radiograph  at  the  end  of  four  weeks,  treatment  being 
by  continuous  extension. 

Fig.  131. — Radiograph  at  the  end  of  five  months :  the  woimd  healed 
in  two  months,  and  union  occurred  at  approximately  the  same  time. 
There  is  a  shortening,  measured  several  times,  of  ^  inch.  On  the 
other  hand,  there  is  rather  marked  stiffness  of  the  knee. 


shaft  may  occur  during  the  course  of  the  second  month. 
This  is  preceded  by  slight  oedema  of  the  edges  of  the 
wound,  and  a  small  amount  of  suppuration:  a  radiograph 
should  be  taken,  and  the  sequestrum  should  be  located 
and  removed  with  forceps.  This  is  usually  easy,  and 
is  followed  by  immediate  disappearance  of  the  symp- 


FRACTURES    OF    THE    FEMUR        543 

toms.     The  procedure  materially  shortens  the  duration 
of  treatment,  and  prevents  the  formation  of  a  sinus. 

Continuous  extension  should  be  prolonged  in  pro- 
portion to  the  age  of  the  patient  and  the  extent  of  the 
original  esquillectomy  ;  walking  should  not  be  per- 
mitted until  three  months  have  elapsed.  I  have  often 
seen  union  occur  between  the  thirty-second  and  fortieth 
day,  and  one  patient  got  up  at  the  end  of  forty-five 
days,  but  this  is  not  an  example  to  be  followed. 

(c)  A  case  is  seen  after  prolonged  suppuration. — In 
a  case  arriving  after  a  month  or  more  of  treatment, 
with  considerable  suppuration  and  daily  rise  and  fall  of 
temperature,  treatment  is  a  difficult  matter.  Complete 
esquillectomy  and  drainage  are  no  longer  possible,  since 
a  considerable  extent  of  the  bone  is  diseased,  and 
inopportune  trauma  would  provoke  an  acute  infection 
the  gravity  and  results  of  which  it  is  impossible  to 
calculate. 

Only  what  is  strictly  necessary  should  therefore  be 
carried  out — freer  drainage  of  the  soft  parts,  removal  of 
easily  accessible  sequestra  without  interfering  with  any 
that  are  adherent,  the  opening  of  abscesses,  and  a 
patient  watch  for  developments.  The  temperature  will 
often  become  normal  and  the  general  condition  im- 
prove as  a  result  of  such  simple  interference,  but  an 
operation  on  the  bone  itself  will  always  ultimately  be 
necessary.  Previous  to  this,  and  after  all  minor  inter- 
ventions, a  warm  moist  dressing  is  very  effective  in 
reducing  the  phenomena  of  sepsis. 

If  the  situation  has  not  distinctly  improved  after 
some  days,  amputation  must  sometimes  be  considered. 
Too  frequently  days  pass  in  hesitation  and  delay,  and 
the  amputation  is  performed  too  late  to  combat  the 
effects  of  chronic  septicaemia.  In  these  cases  I  usually 
perform  a  circular  amputation,  leaving  a  flap  of  skin  of 
greater  length  than  is  necessary,  which  is  well  re- 
tracted ;  the  muscles  are  cut  in  one  transverse  sweep, 
and  the  flap  is  left  turned  back  on  the  skin.     This 


544         TREATMENT   OF   FRACTURES 

gives  complete  exposure  of  the  area  and  is  very  favour- 
able for  the  immediate  arrest  of  septic  conditions. 

Sometimes  high  temperature  persists  after  the  ampu- 
tation, and  the  situation  is  then  one  of  anxiety  :  under 
such  circumstances  I  have  found  it  well  to  employ  a 
large  warm  bath  (102°  F.),  in  which  the  patient  remains 
for  two  hours.  After  the  bath,  I  have  seen  a  regular 
fall  of  temperature  by  lysis,  and  great  improvement 
in  the  general  condition,  the  patient  being  very  soon 
out  of  danger. 

{d)  A  case  is  seen  with  a  sinus. — There  is  no  region 
where  a  bone  sinus  is  more  difficult  to  cure,  when  es- 
quillectomy  has  not  been  performed.  Cases  certainly 
occur,  in  which  the  sinus  is  simply  evidence  of  slight 
superficial  osteitis,  but  more  often  it  leads  to  a  septic 
cavity  or  to  a  deeply  imprisoned  sequestrum.  The 
lardaceous  and  rigid  muscles  form  a  troublesome 
obstacle  to  any  attempt  at  exposing  the  bone,  and 
prevent  exposure  of  the  region  and  free  drainage. 

After  a  precise  conception  of  the  situation  and  extent 
of  the  lesions  has  been  formed  from  a  radiograph,  there 
should  be  no  fear  of  too  comprehensive  an  operation, 
or  hesitation  in  deliberately  sacrificing  sclerosed 
muscular  tissue  which  can  never  function  :  it  is  useless, 
and  extremely  inconvenient. 

(i)  If  ther€,  is  an  osseous  cavity,  one  side  of  it  must  be 
removed,  and  the  edges  bevelled,  that  is  to  say,  it  must 
be  thoroughly  exposed  as  far  as  this  is  possible  :  this 
is  an  essential  condition  for  cure.  When  the  cavity 
has  been  well  disiiifected  by  exposure  to  the  air,  by 
hot  air,  and  particularly  by  the  sun,  it  may  be  plugged 
with  Mosetig's  iodoform  mixture,  or  with  bismuth  in 
the  form  of  Beck's  paste,  which  will  perceptibly  shorten 
the  duration  of  treatment.  I  do  not  mean  that 
secondary  suture  should  be  done  after  the  plugging, 
although  this  is  perhaps  often  possible,  but  it  seems 
scarcely  wise  without  bacteriological  examination ; 
the  only  object  of  the  plugging  is  to  facilitate  oblitera- 


FRACTURES   OF    THE  FEMUR  545 

tion  of  the  cavity  with  newly-formed  tissue.  After 
plugging,  I  leave  the  wound  open  to  the  air  during  the 
day ;  during  the  night,  the  dressing  is  a  simple  sheet 
of  gauze  for  purposes  of  protection.  It  has  seemed 
to  me  that  healing  is  markedly  accelerated  by  this 
procedure. 

(ii)  //  a  sequestrum  is  present ,  it  should  be  cut  down 
upon,  however  large  an  incision  may  be  necessary  for 
the  purpose. 

Here,  more  than  anywhere  else,  random  scraping 
should  be  avoided. 

(c)  When  union  has  occurred  with  marked  shortening. 
—With  a  shortening  of  less  than  1 J  in.  there  is  virtually 
no  lameness.  With  a  shortening  of  2 1  in.  the  patient 
walks  lame,  but  is  not  seriously  inconvenienced ;  it  is 
enough  to  wear  a  thick  sole.  As  a  matter  of  fact, 
shortening  cannot  be  referred  to  as  "  marked,"  and 
be  said  to  necessitate  a  special  boot,  unless  the  difference 
in  length  between  the  limbs  exceeds  2^  in. ;  but  it 
seems  to  me  useless,  in  the  actual  state  of  affairs,  to 
attempt  to  modify  a  shortening  of  less  than  4  in. 

Marked  shortening  is  almost  always  due  to  faulty 
reduction,  vicious  union,  lateral  angulation,  or  over- 
riding. The  most  typical  case  is  that  of  an  exter- 
nally bowed  callus  in  a  fracture  of  upper  part  of 
the  shaft. 

In  these  cases,  correction  of  the  deformity  and 
lengthening  of  the  limb  by  osteotomy  may  sometimes 
be  considered,  but  for  this  the  following  conditions  are 
necessary  : 

(i)  The  fracture  must  not  be  suppurating,  the  callus 
not  osteomyelitic,  there  must  be  no  sequestrum,  sinus, 
or  infected  central  cavity  ;  otherwise  intervention  may 
be  followed  by  fatal  septicaemia. 

(ii)  The  caUus  must  not  be  too  mis-shapen  or  volumin- 
ous ;  otherwise  the  operation  wiU  be  practically 
impossible. 

When  these  two  conditions  do  not  definitely  contra- 


546 


TREATMENT    OF    FRACTURES 


indicate  osteotomy,  a  marked  improvement  in  the 
condition  of  certain  cases  may  be  obtained. 

Oblique  osteotomy  of  the  callus  should  be  performed, 
with  a  minimum  of  trauma  ;  for  this  purpose  a  Gigli 
saw  is  sometimes  preferable  to  the  osteotome.  The 
wound  should  be  left  without  sutures,  and  straightening 
effected  by  continuous  extension  in  a  suitable  position, 
as  for  a  recent  fracture  ;  immediate  straightening  and 
reduction  with  metallic  osteosynthesis  is  not  advisable. 

In  a  fracture  of  the  upper  third  of  the  thigh,  with 


Fig.  132. — Lambotte  tractor 
simplified :  this  was  constructed 
by  a  locksmith  according  to 
Cotte's  instructions. 


marked  deviation  of  the  upper  fragment  in  abduction, 
I  obtained  a  perfect  reduction  in  this  way,  with  re- 
covery of  2  inches  in  length. 

(/)  A  case  is  seen  ivith  a  pseudarthrosis . — This  is  a 
rare  occurrence  ;  up  to  the  present  time,  I  have  only 
seen  pseudarthrosis  of  the  femur  in  the  sub- trochanteric 
region,  and  as  a  result  of  non-reduction. 

Osteosynthesis  by  a  Lambotte  plate  is  definitely 
indicated  in  such  cases. 

(i)  In  sub-trochanteric  fractures  the  condition  of 
the  hip- joint  should  first  be  investigated,  and  an 
attempt  made  to  move  the  fragment  of  the  femur  by 
separating  the  insertions  of  the  pelvi-trochanteric  and 
buttock  muscles  with  a  rugine. 


FRACTURES   OF    THE    FEMUR        547 

If  the  joint  is  immovable  the  shaft  may  simply  be 
fixed  by  a  plate  to  the  sub-trochanteric  border  of  the 
upper  fragment,  which  is  trimmed  for  this  purpose. 
This  causes  marked  shortening  (about  2  in.),  but  the 
result  appears  satisfactory.  I  have  obtained  cure  of  a 
pseudarthrosis  and  a  satisfactory  recovery  of  function 
without  difficulty  by  this  operation  ;  the  plate  remains 
in  position  (observation  eight  months  old). 

(ii)  In  fractures  of  the  shaft  a  considerable  extent  of 
the  femur  should  be  resected,  until,  in  fact,  healthy 
bone  is  reached,  as  in  pseudarthrosis  of  the  humerus. 

Reduction  is  effected  by  a  lever  of  the  Lambotte 
type.  I  have  used  the  simplified  model  illustrated 
above,  which  was  improvised  by  a  locksmith  according 
to  Cotte's  instructions  (fig.  132). 

m.    Supra-condylar  Fractures 

1.  Anatomical  Features. — The  direction  of  the 
fracture  is  usually  oblique  from  behind  forwards  and 
rather  irregular,  with  small  splinters,  particularly 
posteriorly  ;  its  general  appearance  resembles  that  of 
supracondylar  fractures  in  civil  practice.  At  first  the 
damage  often  appears  not  to  be  very  great,  but  in 
reality  there  are  almost  always  several  fissures  radiating 
into  the  joint ;  these  fissures  sometimes  end  at  the 
cartilage,  but  usually  the  latter  is  split,  and  the  fracture 
of  the  shaft  becomes  an  articular  fracture.  There  is 
no  external  sign  of  this  penetration  of  the  epiphysis  ; 
there  is  often  no  hemarthrosis,  and  the  fissure  is  in- 
visible in  a  radiograph,  whatever  its  position,  whether 
intercondylar  or  transcondylar. 

Apart  from  these  cases,  a  T-shaped  and  definitely 
intra-articular  fracture  is  of  common  occurrence. 

There  is  often  considerable  injury  to  the  soft  parts, 
which  is  increased  by  the  rotation  of  the  fragments  ; 
laceration  of  the  tissues  beneath  the  quadriceps 
frequently  occurs. 


548 


TREATMENT   OF    FRACTURES 


The  point  of  the  lower  fragment  sometimes  comes 
into  contact  with  the  popliteal  vessels,  contusing  or 
lacerating  them. 

Nerves  are  usually  uninjured. 
2.  Physiological  Features. — Two  different  forces 
come  into  play  to  produce  the  displacement,  which  is 

usually  very  marked :  by 
the  action  of  the  quad- 
riceps, the  upper  fragment 
is  displaced  forwards,  some- 
times also  slightly  outwards 
or  inwards,  piercing  the 
tendon  of  the  quadriceps, 
and  projecting  beneath  the 
skin  or  into  the  wound. 

The  lower  fragment  is 
pulled  backwards  by  the 
gastrocnemius  and  soleus, 
causing  a  pronounced  rota- 
tion towards  the  popliteal 
space,  and  bringing  the  up- 
per extremity  of  the  epi- 
physeal fragment  into  con- 
tact with  the  vessels. 

3.  Course. — Since  there 
is  little  comminution,  this 
fracture  may  prove  mild, 
provided  that  there  are  no 
transepiphyseal  fissures,  no 
perforation  of  the  joint,  no  vascular  lesion,  and  no 
subsequent  sepsis.  I  have  seen  them  progress  without 
difficulty  (after  early  disinfection),  cure  aseptically 
and  without  complications,  but  with  great  limitation 
of  movements.  In  one  of  these  cases  a  late  ortho- 
paedic resection  was  necessary  and  gave  an  excellent 
result. 

Usually,  however,  the  position  is  less  favourable  ; 
the  epiphysis  is  split  and  the  cartilage  fissured.     If  the 


Fig.  1 33.  —  Supra- condylar 
fracture  :  the  radiograph  does 
not  show  a  fissure  which 
passes  down  between  the  two 
condyles  as  far  as  the  articu- 
lar cartilage. 


FRACTURES    OF    THE    FEMUR        "^-t^ 


wound  is  not  disinfected  immediately,  if  the  fracture 
suppurates,  infection  spreads  along  the  fissure,  and 
after  a  few  days  of  apparently  favourable  progress, 
serious  suppurative  arthritis  suddenly  develops,  and 
immediate  amputation  is  necessary.  During  the  last 
few  months  I  have  been  obliged  to  amputate  in  three 
cases  evacuated  from  the 
front  with  infected  supra- 
condylar fracture.  In  all 
three  cases  amputation  of 
the  thigh  was  necessary 
during  the  course  of  the 
third  week,  shortly  after 
their  transport,  and  in  each 
of  the  three  cases  infection 
of  the  joint  had  occurred 
through  a  radiating  fissured 
transcondylar  fracture; 
there  were  very  marked 
lesions  of  the  cancellous 
tissue  of  the  epiphysis. 

Supra-condylar  fracture 
is  therefore  a  grave  injury. 
When  it  is  added  that  re- 
duction of  the  displacement 
is  always  difficult,  it  will  be 
understood  why  the  prog- 
nosis should  always  be  very 
cautious. 

4.  Indications  for  early 
Treatment. — The  frequent 
occurrence  of  fissures  of  the 
condyles  which  are  invisible 
in  a  radiograph  necessitates 

as  careful  a  preventive  disinfection  as  possible,  with- 
out which  arthritis  is  almost  inevitable. 

This  disinfection  should  include  sub-periosteal  re- 
moval of  all  splinters  projected  into  the  popliteal  space, 


Fig.  134. — Cvire  with  anky- 
losis of  a  supra-condylar  frac- 
tiire  from  a  shell-fragment, 
on  which  no  operation  was 
performed.  A  small  oozing 
sinus  had  persisted  for  a  year 
past :  ankylosis  with  flexion. 
An  orthopaedic  resection  was 
performed,  and  gave  an  excel- 
lent result. 


550         TREATMENT   OF   FRACTURES 

and  careful  and  gentle  curetting  of  the  epiphyseal 
cancellous  tissue. 

If  this  operation  is  performed  at  an  early  stage,  no 
complication  of  the  condylar  lesion  occurs,  even  when  a 
penetrating  fissure  exists.  In  the  case  of  associated 
injury  to  the  synovial  membrane  (which  is  common), 
this  should  be  cleaned,  the  lacerated  borders  of  the 
sjmovial  membrane  excised  and  the  edges  sutured, 
after  which  the  fracture  itself  is  treated. 

If  there  is  laceration  of  the  vessels  they  are  ligatured, 
if  necessary,  without  abandoning  conservative  treat- 
ment, unless  gangrene  is  threatening  or  evident. 

Sometimes,  however,  complete  exploration  will  lead 
to  the  discovery  of  lesions  such  that  immediate  ampu- 
tation will  appear  advisable.  Amputation  should  bs 
performed  if  injury  to  the  bone  is  too  extensive  (ir  ore 
than  4  inches  of  the  femur),  if  the  lesions  of  soft  parts 
(vessels  and  nerves)  are  such  as  to  afford  little  hope  for 
the  future,  if,  together  with  grave  lesions,  there  are 
already  signs  of  articular  infection,  and,  finally,  if 
there  is  gangrene  of  the  foot. 

In  theory,  it  seems  that  amputation  is  rarely  neces- 
sary ;  in  practice  it  frequently  is,  and  after  these 
early  amputations  at  the  front,  subsequent  investiga- 
tion of  the  lesions  almost  invariably  justifies  the  serious 
decision  made, 

5.  Technique. — In  the  absence  of  special  indications 
furnished  by  the  position  of  the  wounds,  the  region  of 
the  fracture  is  approached  by  a  lateral  external  incision 
parallel  to  the  biceps,  but  slightly  anterior  to  it,  and 
ending  below  at  the  condylar  prominence.  Unless  an 
internal  incision  is  necessary  to  reach  splinters  that 
have  been  projected  inwards,  this  single  incision  will 
suffice,  which  is  an  advantage  from  the  point  of  view 
of  the  vessels  and  nerves.  An  incision  in  the  popliteal 
space  is  bad,  and  should  never  be  made  :  drainage,  in 
contact  with  the  popliteal  artery  and  branches  of  the 
sciatic  nerve  would  be  particularly  misplaced. 


FRACTURES    OF    THE    FEMUR         551 

As  a  rule,  the  operation  is  easy. 

The  same  cannot  be  said  of  the  immobilisation  of 
these  fractures.  The  backward  rotation  of  the  lower 
fragment  necessitates  immobilisation  with  the  leg 
flexed,  and  the  forward  projection  of  the  upper  frag- 
ment necessitates  flexion  of  the  thigh  on  the  pelvis. 

Any  form  of  immobilisation  with  continuous  ex- 
tension which  does  not  take  these  two  desiderata  into 
account  should  therefore  only  be  temporary. 

As  a  provisional  arrangement,  at  the  front,  the 
plaster  trough  is  a  solution  of  mediocre  value,  but 
acceptable  for  the  time  being  ;  as  soon  as  possible,  the 
double  inclined  plane  should  be  resorted  to,  which  may 
easily  be  improvised  with  two  boards  of  equal  dimen- 
sions, united  by  two  hinges,  and  fixed  by  a  rack. 

When  a  choice  is  possible,  Hey-Groves's  appliance 
(described  on  p.  523 )  should  be  used,  and  is  excellent 
from  this  point  of  view  ;  the  suspension  appliance  with 
a  jointed  frame  (as  illustrated  on  p.  529,  fig.  118)  is 
good.  I  have  treated  a  high  supra-condylar  fracture 
by  means  of  this  appliance,  and  obtained  an  excellent 
reduction.  I  refer  the  reader  to  details  given  in  con- 
nection with  the  above-mentioned  splint. 

6.  Treatment  of  cases  seen  at  a  -later  stage 
OR  AFTER  PREVIOUS  TREATMENT. — (a)  A  case  is  Seen 
progressing  well. — This  is  unusual,  and  up  to  the 
present  I  have  never  admitted  from  the  front  a  supra- 
condylar fracture,  due  to  a  shell-fragment,  in  a  good 
condition.  Immobilisation  should  be  effected,  as  has 
been  stated  above,  on  a  double  inclined  plane.  Con- 
tinuous extension  is  not  always  necessary,  but  if  it 
should  be,  it  is  carried  out  by  exerting  a  strong  down- 
ward pull  on  the  condyles,  in  an  attempt  to  rotate  the 
lower  fragment  back  into  position. 

Immobilisation  should  be  continued  for  three  or  four 
months.  Union  in  these  epiphyseal  fractures  is  often 
very  slow.  Considerable  stiffness  of  the  knee  must  be 
expected. 


553 


TREATMENT   OF   FRACTURES 


(&)  A  cast  is  seen  in  a  septic  condition. — Three  types 
of  condition  are  possible : 

(i)  If  it  is  a  fracture  which  has  not  been  disinfected, 
immediate     esquillectomy     is     necessary.     The     two 

pointed  ends  are  smoothed 
off  with  a  Gigli  saw.  Any 
radiating  fissure  should  be 
located  and  cleaned  with 
a  curette,  the  cancellous 
tissue  in  its  vicinity  being 
scraped  away.  If  neces- 
sary, hemarthrosis  of  the 
knee  is  relieved  by  punc- 
ture. 

If  a  penetrating  fissure 
exists,  resection  of  the 
knee  should  be  performed 
at  once,  including  removal 
of  a  thin  layer  from  the 
tibia. 

If  the  infection  is  not 
rapidly  checked,  the    at- 
tempt     at     preservation 
should  not  be  continued 
too  long,  but  amputation 
should  be  performed  with- 
out delay,  even  if  the  line 
of  fracture  and  consequent 
shape  of  the  upper  frag- 
ment are  favourable  for  re- 
section of  the  knee  ;  these 
fractures  are  very  serious 
when  preventive  disinfec- 
tion has  failed, 
(ii)  If  the  fracture  is  seriously  infected,  with  evident 
injury  to  the  joint,   which  is  also  already  infected, 
resection  is  sometimes  possible,  but  more  often  im- 
mediate  amputation   is   necessary.    A    few   isolated 


Fig.  136.  —  Supra  -  condylar 
fracture  treated  at  the  front 
by  drainage  of  the  soft  parts 
and  intermittent  irrigation. 
Evacuation  on  the  fifteenth  day  ; 
condition  apparently  good.  Four 
days  later,  suppurative  arthritis 
and  serious  general  condition ; 
amputation  of  the  thigh.  An 
infected  fissure,  which  the  radio- 
graph does  not  show,  passed 
through  the  outer  condyle  as  far 
as  the  cartilage,  which  was  split. 


FRACTURES  OF   THE   FEMUR        55  3 

fortunate  cases,  which  will  never  be  anything  but 
exceptions,  cannot  blind  us  to  the  fact  that  deaths 
have  been  caused  by  undue  delay  in  amputating  in 
these  fractures. 

(iii)  If  the  foot  is  gangrenous,  which  indicates  a 
vascular  lesion,  amputation  is  also  necessary. 

(c)  A  case  is  seen  with  vicious  union. — There  are 
vicious  unions  which  should  be  recognised  as  unsuitable 
for  intervention — viz.  those  which  are  still  infected, 
or  are  accompanied  by  a  large  inflamed  callus.  On  the 
other  hand,  effective  intervention  is  possible  by 
orthopaedic  resection,  in  simple  vicious  union,  due  to 
absence  of  reduction,  with  a  stiffness  of  the  joint 
practically  amounting  to  ankylosis :  very  limited 
orthopaedic  resection  of  the  tibia  has  enabled  me  to 
obtain  a  firm  knee  in  the  extended  position.  The  same 
is  the  case  when  the  shaft  of  the  bone  becomes  impacted 
into  the  condyles  in  a  position  of  angular  deformity. 
In  a  case  suffering  from  ankylosis  with  flexion  of  this 
kind,  resection  gave  me  a  perfect  result  (fig.  134). 

(d)  A  case  is  seen  with  a  pseudarthrosis. — I  have  never 
seen  an  example  of  this,  but  it  is  a  possibility,  pseudar- 
throsis being  caused  by  lack  of  reduction  and  muscular 
interposition.  Operation  on  the  region  of  the  fracture 
and  introduction  of  a  Lambotte  plate  on  the  outer  side 
seem  to  me  the  best  procedures. 

(e)  A  case  is  seen  with  a  sinus. — ^AU  sinuses  which  I 
have  seen  co-existed  with  ankylosis  of  the  knee,  and 
curetting  of  the  cancellous  tissue  after  this  has  been 
widely  exposed  by  a  transverse  incision  easily  pro- 
duced a  satisfactory  result.  The  conditions  may, 
however,  be  different :  notably,  multiple  sinuses  may 
occur,  due  to  different  causes — cancellous  osteitis 
below,  a  sequestrum  from  the  shaft  above  and  behind. 
In  these  cases  the  operation  should  consist  of  several 
stages,  each  lesion  being  treated  separately  according 
to  the  nature  of  its  cause. 


CHAPTER   XYI 
FRACTURES  OF  THE  LEG 

The  following  groups  may  be  distinguished  : 

Fractures  of  both  bones  about  the  middle,  and  in  the 

lower  third  (supra-malleolar). 
Fractures  of  the  tibia  alone. 
Fractures  of  the  fibula  alone. 

I.    Fracture  of  Both  Bones  of  the  Leg 

In  practice,  fracture  of  the  upper  epiphyses  of  the 
bones  of  the  leg  is  only  seen  as  an  injury  to  the  joint, 
which  should  be  treated  by  resection.  Fractures  of 
the  malleoli  are  also  almost  always  fractures  into  the 
joint.  I  shall  only  deal  here  with  definitely  diaphyseal 
and  supra-malleolar  fractures. 

A.  Fractures  of  both  Shafts. — This  term  includes 
any  fracture  between  the  tuberosity  of  the  tibia  and 
the  lower  third  of  both  bones,  2  in.  from  the  malleolus. 

1.  Anatomical  Features. — The  most  usual  type  of 
fracture  has  large  diamond-shaped  splinters  in  the 
tibia,  and  comminution  of  the  fibula.  Fracture  of  the 
tibia  of  the  large  short-splinter  type,  with  transverse 
fracture  of  the  fibula,  also  occurs,  and  still  more  com- 
mon is  comminution  of  both  bones. 

The  higher  up  the  fracture  {i.e.  the  nearer  to  the 
upper  tibial  epiphysis)  the  more  frequent  is  the  com- 
minuted type.  On  the  other  hand,  the.  lower  down  the 
position  of  the  fracture,  the  more  often  does  the  large- 
splintered  type  occur. 

Lesions  of  the  vessels  and  nerves  are  very  frequent. 

554 


FRACTURES   OF   THE   LEG 


555 


2.  Physiological  Features. — ^The  displacement  is 
always  more  marked  in  the  tibia  than  in  the  fibula. 
There  are  two  opposing  muscular  forces — that  of  the 
quadriceps  femoris,  which  pulls  the  upper  fragment 
forwards,  and  that  of  the  calf  muscles,  which  tries  to 
displace  the  lower  fragment  backwards.  The  result 
is  a  frequent  angular  displacement  with  its  apex  back- 
wards ;  the  leg 
appears  to 
form  a  curve 
with  a  marked 
anterior  c  o  n- 
cavity.  At  the 
same  time 
there  is  almost 
always  lateral 
displacement. 
Lastly,  the 
weight  of  the 
foot  usually 
exerts  a  lateral 
pull  on  the 
lower  f  rag- 
ment,  pro- 
ducing  a  cer- 
tain degree  of 
rotation  on  the 
long  axis  of  the 
bone,  i.e.  in- 
ternal or  ex- 
ternal displacement  by  torsion.  In  spite  of  this,  the 
displacement  is  never  very  great. 

3.  Course. — ^When  left  alone,  a  fracture  of  both 
bones  is  often  complicated  by  gas  gangrene,  since  there 
is  extensive  muscular  injury  beneath  resistant  fascige, 
and  often  associated  vascular  lesions. 

In  cases  which  escape  these  immediate  complica- 
tions, the  development  of  serious  septic  acute  osteo- 


FiG.  136.— Large- 
splintered  fracture  of 
the     tibia     (common 

type). 


Fig.  137.— Postero- 
lateral angvilation  in 
a  fracture  of  the  leg. 


5r)ti  TREATMENT   OF   FRACTURES 

myelitis  of  the  fractured  area  is  virtually  constant  and 
leads  to  the  formation  of  sequestra,  profuse  suppura- 
tion, pus  tracking  down  the  calf,  destruction  of  the 
fasciae,  and  secondary  haemorrhage. 

After  drainage,  which  causes  permanent  rigid  and 
contractile  cicatrices  in  the  muscles,  one  of  two  con- 
ditions usually  develops  :  either  a  redundant  inflamed 
callus  is  formed,  enclosing  an  empty  medullary  cavity 
(see  p.  30G,  figs.  10  and  11),  or  the  dull  white  ex- 
tremities of  the  tibial  fragments  undergoing  necrosis 
are  seen  in  the  wound,  and  after  their  elimination,  the 
devitalised  ends  of  the  shaft  are  left  rarefied  and  with- 
out any  sign  of  union,  and  decidedly  unsuited  for 
plating. 

Of  these  conditions  the  former  is  the  more  common. 
Owing  to  the  suppuration,  it  is  difficult  to  ensure  rigid 
immobilisation,  and  a  frequent  result  is  the  formation 
of  a  faulty  callus  with  posterior  angulation,  so  that  the 
leg  forms  a  bold  curve  with  its  concavity  forward,  or 
with  outward  or  inward  displacement  by  torsion  of 
the  foot,  and  almost  always  a  degree  of  pes  equinus, 
which  soon  becomes  difficult  to  correct. 

In  short,  the  cure  of  septic  fractures  of  the  leg  is  too 
often  only  very  moderately  satisfactory  :  in  these, 
more  than  in  fractures  in  any  other  region,  anatomical 
preservation  is  by  no  means  identical  with  preservation 
of  function. 

4.  Indications  for  early  Treatment. — A  pro- 
phylactic clearing  operation  should  be  done  as  early  as 
possible  :  this  is  a  sine  qua  non  if  good  functional  use 
is  to  be  hoped  for. 

There  are  cases,  however,  in  which  this  immediate 
operative  disinfection  is  only  a  prelude  to  immediate 
amputation. 

Amputation  should  be  performed  at  once  when  destruc- 
tion of  the  bone  is  too  extensive  to  afford  any  hope  of 
adequate  anatomical  repair.  Judgment  on  this  point 
is  not  an  easy  matter,  and  the  decision  in  such  a  case 


FRACTURES   OF    THE   LEG  557 

depends  largely  on  the  individual.  In  general,  it  is 
better  to  err  in  the  direction  of  too  frequent  attempts 
to  preserve  the  limb ;  sub-periosteal  esquillectomy 
allows  one  to  go  very  far  in  this  direction  without 
danger. 

It  would  seem,  however,  that  when  the  bone-injury 
involves  more  than  half  the  length  of  the  leg  (not,  of 
course,  including  fissures,  but  merely  the  splintered 
region),  immediate  amputation  is  preferable. 

Similarly,  when  the  injuries  to  soft  parts,  muscles, 
vessels,  and  nerves,  are  such  as  to  afford  no  hope  of 
satisfactory  functional  recovery,  it  is  better  to  ampu- 
tate at  once,  since  preservation  would  cause  the  patient 
to  run  considerable  risks  for  an  illusory  benefit. 

Finally,  the  seriousness  of  the  general  condition  may 
sometimes  necessitate  an  early  amputation,  when  an 
extensive  area  has  been  comminuted.  But  I  regard 
this  indication  as  extremely  rare  ;  the  necessity  only 
exists  when  it  is  of  importance  to  demand  a  minimum 
of  effort  from  the  system  {e.g.  when  the  patient  is 
almost  bloodless,  and  in  danger  of  grave  infection). 
Even  in  such  a  condition  as  this,  a  more  appropriate 
course  than  amputation  would  probably  be  trans- 
fusion, followed  by  esquillectomy  later  on. 

In  all  other  cases,  early  sub-periosteal  esquillectomy 
should  be  performed  at  once,  for  the  two  reasons 
already  mentioned — to  prevent  complications,  and  to 
facilitate  union. 

5.  Technique. — (a)  The  operation. — This  is  per- 
formed by  means  of  two  incisions,  one  along  the  crest 
of  the  tibia,  and  the  other  over  the  fibula,  the  existing 
wounds  being  used  if  convenient ;  there  should  be  no 
hesitation  in  making  fresh  incisions  at  the  seat  of 
election  if  the  entry  and  exit  wounds  are  inconveniently 
situated. 

The  tibial  incision  should  be  made  on  the  aspect  of 
the  bone  internal  to  the  crest :  separation  of  the 
periosteum  with  the  rugine  is  begun  at  once  and  as 


558 


TREATMENT   OF   FRACTURES 


much  of  this  as  possible  is  preserved  ;  the  region  of 
the  fracture  should  be  carefully  cleaned,  and  if  neces- 
sary, sound  bone  cut  away  from  the  antero-internal 
surface  of  the  tibia  in  order  to  expose  its  posterior 
aspect.  Esquillectomy  is  then  carried  out  in  the 
fibula,  but  this  need  not  be  so  ex- 
tensive, as  the  fragments  over-ride 
without  any  trouble,  when  the  dif- 
ference between  the  gaps  in  the  two 
bones  is  not  too  great.  Unless  this 
precaution  be  taken,  the  orthopaedic 
result  is  not  satisfactory  ;  mechani- 
cal forces  do  not  act  normally  on 
the  fragments,  the  progress  of  bone 
formation  in  the  two  bones  is  not 
correctly  correlated,  and  there  is 
danger  of  faulty  union  at  some 
point,  if  not  of  pseudarthrosis.  The 
shortening  of  the  fibula  should  there- 
fore be  systematically  ensured. 

At  the  conclusion  of  the  operation, 
it  is  absolutely  useless  to  make  an 
incision  through  the  muscles  of  the 
calf,  for  purposes  of  drainage  ;  the 
sole  effect  of  this  is  to  leave  dense 
scar-tissue  in  them. 

(6)  Immobilisation. — The  essential 
point  is  that  this  should  ensure  pre- 
servation of  the  normal  axis  of  the 
lower  limb,  since  any  deviation  from 
the  normal  static  line  has  infinitely 
more  serious  functional  results  than  has  shortening. 
During  the  whole  period  of  immobilisation,  therefore, 
any  angular  deviation  must  be  accurately  corrected 
and  every  effort  must  be  made  to  re-establish  the  long 
axis  of  the  tibia. 

During  the  first  few  days  I  employ  a  metal  splint, 
pending  the  first  dressing.     The  latter,  if  conditions 


Fig.  138.— Radio- 
graph after  total 
sub-periosteal  e  s  - 
quillectomy.  The 
leg  is  in  a  continous 
extension  plaster 
apparatus,  of  the 
type  represented  in 
fig.  138  (cf.  figs.  136 
and  137). 


FRACTURED    OF    THE    LEG  559 

are  normal,  is  postponed  until  the  sixth  or  eighth  day, 
when  I  finally  immobilise  the  limb  by  one  of  the  three 
following  procedures  : 

A  simple  posterior  plaster  trough  suffices  in  many 
cases,  where  esquillectomy  has  effected  a  complete 
reduction,  and  there  is  no  sepsis  to  necessitate  frequent 
dressing  (Part  I,  fig.  70). 

In  a  case  of  this  kind,  good  union  was  observed  to 
have  occurred  in  thirty-seven  days,  when  the  third 
dressing  was  applied. 

More  often,  however,  a  continuous  extension  appliance 
is  necessary. 

Excellent  permanent  traction  can  be  applied  by  the 
use  of  plaster,  in  the  following  way  : 

Two  sets  of  curtain-rods  are  prepared,  one  rod 
sliding  on  the  other  in  each  case ;  these  are  cut  so  that, 
allowing  for  a  fair  amount  of  extension,  the  two  rods 
fitted  one  over  the  other  are  about  equal  in  length  to 
the  leg  (fig.  139).  A  well-modelled  plaster  boot  is 
then  made,  not  fitting  too  tightly,  and  in  the  centre 
of  the  sole  is  incorporated  a  loop  of  bandage,  or  a  metal 
hook,  to  act  as  a  traction  ring.  The  knee  is  next 
enclosed  in  plaster,  which  extends  down  immediately 
below  the  anterior  tuberosity  of  the  tibia.  The  two 
parts  of  the  plaster  are  connected  on  each  side  by 
means  of  a  pair  of  the  telescopic  shafts,  which  are  held 
in  position  by  an  assistant  three  fingers'  breadth  away 
from  each  side  of  the  leg.  Each  shaft  is  fixed  firmly 
to  the  plaster  at  one  end  (fig.  139)  by  means  of  a 
plaster  band  rolled  as  is  indicated  in  figs.  140  and  141. 
The  assistant  keeps  the  telescopic  traction  shafts 
exactly  parallel  to  the  axis  of  the  leg  until  the  plaster 
is  dry,  this  being  done  first  on  one  side  and  then  on 
the  other.  A  small  splint  should  be  incorporated  in 
the  dressing  behind  during  the  first  few  days  to  sup- 
port the  calf. 

I  have  treated  a  considerable  number  of  serious 
fractures    with    this    improvised   appliance,    and   the 


5G0 


TREATMENT   OF   FRACTURES 


results  have  been  excellent.    It  is  only  necessary  to  be 
extremely  careful  not  to  immobilise  the  bones  in  a 


Fig.  139. — Continuous  extension  plaster  apparatus. 


bent  position,  and  to  push  the  upper  fragment  forwards 
before  fixing  the  metal  shafts. 


Fig.  140. — ^Method  of  fixing  the  sliding  rods  :  the  band  passes 
from  the  plaster  to  the  outer  shaft,  and  is  then  wound  in  a  spiral 
around  the  original  loop. 

Further  simplification  is  sometimes  possible,  nothing 
being  applied  to  the  upper  part  of  the  leg  but  a  plaster 


FRACTURES   OF    THE   LEG  561 

collar  identical  with  that  in  Delbet's  walking  appliance 


Fig.  141. — Finally,  regular  circular  turns  are  made  round  the 
plaster  bridge  which  has  thus  been  made. 


Fig.  142. — Diagram  of  a  suspension  appliance  for  fracture  of 
the  leg  :  the  three  suspension  pulleys  are  attached  to  a  horizontal 
bar  of  the  ordinary  type. 

the  knee  remains  free,  and  a  certain  amount  of  flexion 
is  possible.    As  a  matter  of  fact,  it  is  preferable  not  to 


562 


TREATMENT    OF    FRACTURES 


employ  this  form  of  the  appliance  until  the  fracture  is 
well  on  the  way  to  unite.  The  telescoping  curtain-rods 
may  be  replaced  by  a  double  spring  shaft,  comparable 
to  those  in  Delbet's  appliance  (fig.  37,  p.  376). 

But  in  bad  fractures  with  extensive  injuries  to  the 
soft  parts,  these  appliances  cannot  be  used  ;  in  these 
cases  the  suspension  appliance  is  the  most  suitable. 

An  appliance  may  be  used  which  is  identical  with 
those  described  on  p.  528  for  fracture  of  the  thigh,  and 


Fiu.  143. — Continuous  extension  plaster  for  a  fracture  which  is 
uniting,  but  with  associated  pes  equinus  :  correction  of  the  latter 
slow,  owing  to  previous  articular  suppuration. 

continuous  traction  may  be  exerted,  the  entire  lower 
limb  being  in  extension.  It  is  better,  however,  to  use 
a  jointed  frame,  traction  being  exerted  with  the  knee 
flexed.  The  practical  details  given  in  connection  with 
supra-condylar  fractures  of  the  femur  render  further 
description  of  the  appliance  unnecessary.  Its  con- 
struction is  shown  in  fig.  142.  The  counterpoise 
should  be  from  4  to  5  kilogrammes,  and  the  extension, 
from  a  strapping  stirrup,  5  to  6  kilogrammes. 

(c)  Care  of  the  foot. — It  is  absolutely  necessary  to 


FRACTURES   OF    THE    LEG 


563 


watch  the  position  of  the  foot.  Bad  positions  of  the 
foot  too  often  spoil  the  functional  result  after  perfect 
union  of  the  fracture.  Moreover,  a  number  of  these 
abnormal  positions  are  due  to  reflex  contractures 
which  are  difficult  to  cure.  Continual  attention  should 
be  given  to  the  foot,  in  order  to  prevent  the  develop- 
ment of  equinus,  varus,  or  valgus.  These  details 
should  receive  consideration  early  in  the  treatment, 


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Fig.  144. — (A)  Tibial  piece.  (B)  Malleolar  piece  with  heel- 
covering.  (C,  D)  Lateral  supports,  4  inches  being  folded  back  at 
the  lower  extremity.     (E)  Malleolar  piece  with  heel  piece. 

and  not  towards  the  end.  If  the  deformity  already 
exists  but  has  not  developed  too  far,  the  normal 
position  of  the  foot  can  be  restored,  either  by  means  of 
a  spring  sole,  or  by  an  arrangement  such  as  that  shown 
in  fig.  143. 

{d)  Apparatus  for  convalescence. — As    soon    as   the 
size  of  the  wounds  is  reduced,  and  union  has  begun. 


r)H4         TREATMENT    OF    FRACTURES 


it  is  an  excellent  practice  to  fit  Delbet's  walking 
appliance.  This  is  usually  permissible  about  forty 
days  after  the  operation  when  there  is  no  longer  any 
need  for  continuous  extension.  The  Scultet  apparatus, 
which  Delbet  considers  necessary,  is  not  really  called 
for  :  it  may  perhaps  be  more  convenient,  but  I  do  not 

use  it.     To  construct   an   ap- 
pliance for  walking,    four  tar- 
latan   slips  of  the   dimensions 
indicated   in  fig.   144   are  pre- 
pared, and  a  fairly  thin  plaster 
paste,  intended  not  to  set  too 
quickly.     The  slips  and  circular 
pieces  are  soaked  in  the  liquid 
paste,     spread     on     a     table, 
smoothed,  sprinkled  with  dry 
plaster,  and  placed  flat  on  the 
leg.     The  malleolar  ring  is  first 
applied,  in  such  a  way  that  the 
heel-cover    does    not     extend 
below  the  heel.     The  circular 
tibial  piece  is  similarly  applied  ; 
the  upper  border  of  this  should 
coincide    with,     but   not   pass 
above,  the  anterior  tuberosity 
of  the  tibia.      The  two  lateral 
supports   are   immediately  ap- 
plied, care  being  taken  not  to 
encroach   on  the    knee  above, 
and  to  reach  the  border  of  the 
foot  below,  without  passing  beyond  it.     The   upper 
collar  is  then  arranged  circularly  around  the  leg  and 
the    two   ends  of    the   heel-piece  are  made  to  cross 
anteriorly  above  the  instep,  which  should  remain  free. 
Nothing  now  remains  but  to  mould  the  whole  to  the 
limb  with  an  ordinary  bandage,  being  careful  to  keep 
the  foot  exactly  at  a  right  angle,  while  moulding  the 
heel-covering  on  the  malleoli. 


Fia.  145.  —  Delbet's 
walking  appliance  for 
fracture  of  the  leg. 


FRACrVEES    OF    THE    LEG 


Ofi.j 


6.  The    Treatment   of  cases   seen  at  a  later 

STAGE  OR  AFTER  PREVIOUS  TREATMENT. — {(l)    A    case 

is  seen  doing   well   after   several    days. — The    wounds 
are  insignificant,  and  the  fracture  is  apparently  going 


Fio.  146  Fig.  147.  Fia.  148. 

Fig.  146. — Severe  fracture  of  both  bones  ot  the  leg  caused  by  a 
shell-fragment ;  sub-periosteal  esquillectomy  on  the  fourth  day, 
followed  by  removal  on  the  eleventh  of  a  splinter  that  had  been 
overlooked  ;    radiograph  on  the  fourteenth  day. 

Fig.   147. — Radiograph  two  months  later. 

Fig.  148. — Radiograph  at  the  end  of  eight  months.  Union  took  four 
months,  and  was  effected  in  a  continuous  extension  plaster  of  the 
type  represented  in  fig.  139,  In  spite  of  the  tibio-fibular  synostosis, 
the  longitudinal  axis  of  the  bone  is  preserved  ;  the  result,  from  the 
point  of  view  of  function  and  equilibrium,  is  good.  Musculature  good. 
No  sinus.     Shortening  of  half  an  inch. 


on  as  if  it  were  caused  by  a  bullet  with  punctiform 
wounds.  It  is  necessary  and  sufficient  to  apply  con- 
tinuous extension  for  three  or  four  weeks,  and  then  to 
fit  a  walking  appliance. 


566  TREATMENT   OF   FRACTURES 

(&)  A  case  is  found  to  he  infected. — The  wound  dates 
from  sofne  days  previously,  the  leg  is  swollen,  and 
there  is  suppuration.  Complete  sub-periosteal  es- 
quillectomy  of  both  bones  should  be  performed  at 
once,  care  being  taken  to  reduce  the  fibula  to  the  same 
length  as  the  tibia.  Abscesses  should  be  opened,  but, 
except  when  definitely  necessary^  no  posterior  counter- 
incision  for  drainage  is  made,  as  this  is  useless.  Im- 
mobilisation in  plaster,  with  continuous  extension,  or 
in  suspension,  is  immediately  effected. 

Under  these  conditions,  if  the  case  is  carefully 
dressed  and  the  position  of  the  fragments  continually 
re-examined,  marvellous  results  will  be  obtained  :  very 
grave  fractures  will  be  cured  without  leaving  any 
effects,  and  function  will  be  recovered  practically 
entirely  (figs.  135,  136,  137,  145). 

The  position  of  the  foot  must  be  watched  carefully 
in  these  cases  :  it  will  sometimes  be  necessary  to 
contend  with  pes  equinus ;  in  a  complex  case,  in 
which  I  was  obliged  to  perform  arthrotomy  of  the 
ankle  during  treatment  of  a  serious  fracture,  I  used 
the  arrangement  indicated  in  fig.  139  to  counteract 
pes  equinus  and  to  restore  the  foot  to  its  normal 
position. 

(c)  A  case  is  seen  at  a  late  stage,  seriously  infected. — 
The  first  month  has  passed,  the  periosteum  has  already 
reacted,  and  the  outlines  of  a  callus  have  been  formed, 
but  the  wound  is  suppurating  profusely,  and  sequestra 
are  beginning  to  be  eliminated.  At  this  stage,  es- 
quillectomy  is  no  longer  possible  ;  the  treatment  will 
be  merely  drainage  of  the  soft  parts  and  removal  of 
sequestra  that  require  to  come  away.  Intervention, 
if  it  is  not  to  be  dangerous,  must  be  delayed  until  the 
osteomyelitis  has  been  reduced  to  some  extent. 

If  the  lesions  are  very  extensive,  if  the  general  con- 
dition becomes  v*  orse,  if  the  temperature  remains  high 
after  adequate  drainage,  and  particularly  if  the  shorten- 
ing, due  to  elimination  of  sequestra,  is  marked  (3  to 


FRACTURES    OF    THE    LEG  567 

4  in.),  and  there  are  serious  associated  muscular  and 
nervous  lesions,  it  will  sometimes  be  necessary  to 
decide  on  amputation.  Late  secondary  amputation  has 
two  indications  which  are  very  real,  but  difficult  to 
express  :  it  should  be  considered  (1)  when  the  general 
condition  does  not  justify  waiting  too  long  for  slow  and 
probably  poor  anatomical  repair,  and  (2)  when  the 
local  conditions  afford  no  hope  of  sufficient  functional 
recovery. 

{d)  A  case  is  seen  with  a  fistulous  callus. — In  general 
the  tibia  is  concerned,  and  there  is  either  an  osteo- 
myelitic  central  cavity,  with  or  without  sequestra,  or 
the  bone  is  thickened  by  a  condensing  osteitis,  which 
keeps  up  persistent  ulceration  of  the  skin. 

In  the  former  case,  after  careful  separation  of  the 
periosteum,  the  wall  of  the  cavity  must  be  cut  away 
and  smoothed,  exposing  the  medullary  canal,  in  order 
that  the  cavity  may  be  disinfected  by  exposure  to  the 
air,  and  ultimately  filled  in. 

In  the  latter  case,  the  hypertrophic  bone  must  be 
gouged  away,  and  the  bone  cut  down  ,until  the  medullary 
canal,  or  what  remains  of  it,  is  encountered,  not  by 
hollowing  out  a  narrow  groove,  but  by  chiselling  away 
the  bone  over  a  large  area  :  there  is  no  danger  of 
carrying  this  too  far. 

Sinuses  and  osteitic  ulceration  may  always  be 
cured  successfully  in  this  way. 

(e)  A  case  is  seen  with  a  pseudarthrosis . — -Usually 
pseudarthrosis  only  occurs  in  the  tibia  ;  it  is  a  more  or 
less  compact  fibrous  pseudarthrosis  with  bony  union 
in  the  fibula.  It  is  most  common  in  the  upper  third 
of  the  bone  at  the  junction  of  the  epiphysis  and  shaft. 
Lower  down,  if  union  fails,  it  generally  does  so  in  both 
bones. 

Before  undertaking  any  treatment,  the  region  must 
be  disinfected  if  any  sign  of  infection  remains,  sinuses 
must  be  cleaned,  and  sequestra  removed  ;  then  the 
area  is  widely  exposed,  without  waiting  for  cutaneous 


568 


TREATMENT   OF    FRACTURES 


healing,  the  fibrous  tissue  between  the  two  fragments 
is  excised,  and  the  extremities  of  the  shaft  are  resected 
on  each  side  until  apparently  healthy  tissue  is  en- 
countered. When  two  healthy  surfaces  of  bone  have 
been  thus  obtained,  sufficient  of  the  fibula  is  resected 
sub-periosteally  to  permit  apposition,   and  the  tibia 


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Fio.  149. — Vicious  callus  with 
multiple  sinuses  a  year  old. 


Flo.  150. — Forcible  reduction 
with  osteosynthesis  :  uneventful 
recovery. 


is  fixed  by  one  or  two  Lambotte  plates.  The  wounds 
are  left  open,  without  sutures,  and  rigorous  immobilisa- 
tion is  effected  with  plaster. 

By  this  method  I  have  brought  about  union  without 
difficulty  in  the  few  cases  of  pseudarthrosis  of  the  leg 
on  which  I  have  operated. 

Bone-grafting  is  not  advisable  at  this  stage  :    or- 


FRACTURES    OF    THE    LEG  509 

ganisms  are  latent  in  the  tissues  and  no  reliance  can  be 
placed  on  the  result.  I  have  never  performed  the 
operation,  but  at  medical  boards  I  have  seen  numerous 
failures,  of  which  one  hears  nothing. 

Lastly,  there  are  pseudarthroses  which  require  ampu- 
tation. It  must  be  remembered  that  the  leg  exists  to 
carry  the  weight  of  the  body  in  walking.  If  the 
pseudarthrosis  is  incurable,  or  if  operation  could  only 
end  in  so  much  shortening  that  function  would  be 
irremediably  lost,  amputation  is  preferable,  and  it 
is  useless  to  defer  it. 

if)  A  case  is  seen  with  a  vicious  callus. — If  the 
callus  permanently  interferes  with  walking,  both  bones 
must  be  re-fractured,  and  the  misshapen  callus  must 
be  cut  away  with  chisel  and  mallet  until  the  newly 
formed  bone  has  been  removed  and  reduction  has 
become  possible.  When  this  has  been  done,  tibial 
osteosynthesis  is  effected  with  a  metal  plate ;  the 
wounds  are  left  open,  without  suture,  and  the  leg  is 
carefully  immobilised  in  a  posterior  plaster  splint : 
a  very  satisfactory  result  will  generally  be  obtained 
(figs.  149  and  150). 

B.  Supra-malleolar  Fractures.  —  1.  Anatomical 
Features. ^According  to  my  experience,  there  is 
usually  one  main  line  of  fracture  in  the  tibia,  separating 
the  epiphyseal  end  from  the  shaft.  This  is  flanked 
either  behind  or  in  the  space  between  the  tibia  and 
fibula  by  two  or  three  scale-like  fragments  which  may 
extend  down  into  the  ankle-joint.  The  line  of  fracture 
may  be  definitely  transverse  ;  more  often,  it  is  oblique 
antero-posteriorly  and  from  above  downwards.  In 
these  cases  the  lower  fragment  has  a  very  sharp  upper 
point,  about  3  inches  in  length.  It  might  be  described  as 
an  incomplete  spiral  fracture.  There  is  a  comminuted 
fracture  of  the  fibula  without  displacement  of  the  small 
longitudinal  splinters. 

2.  Physiological  Features. — In  transverse  frac- 
tures the  foot  is  pulled  backwards  and  upwards  by 


570 


TREATMENT    OF    FRACTURES 


the  gastrocnemius,  soletis,  and  plantaris,  and  the  shaft 
fragment  projects  forwards; 

In  oblique  fractures  the  foot  rotates  backwards  in 
the  same  way,  and  the  lower  fragment,  the  point  of 

which  forms  a  projection 
anteriorly,  faces  upwards 
and  backwards,  while  the 
upper  fragment  is  carried 
downwards  and  back- 
wards by  the  action  of 
the  flexors  of  the  foot. 
Lateral  deviation  almost 
always  exists,  but  not  in 
any  constant  direction. 

3.  Course.  —  The  gra- 
vity of  these  fractures  is 
due  to  the  possibility  of 
secondary  infection  of  the 
joint  through  radiating 
fissures,  and  also  to  the 
difficulty  of  reduction. 

If  the   lesion   becomes 

septic,     arthritis    of     the 

ankle-joint     is     possible, 

and  sometimes    leads   to 

amputation    of    the    leg. 

Pus  may  also  track  along  the  tendon  sheaths,   and 

sometimes  forms  a  prominence  in  the  sole  of  the  foot. 

In  the  most  simple  cases  a  large  deformed  callus 

forms,  and  the  position  is  bad. 

In  my  opinion,  these  fractures,  orthopaedically  speak- 
ing, and  from  the  point  of  view  of  functional  restora- 
tion, are,  with  the  exception  of  those  of  both  bones  of 
the  forearm,  the  most  difficult  fractures  to  treat. 

Little  control  of  the  lower  fragment  is  possible,  and 
unless  it  is  inadequately  restored  to  its  proper  position, 
a  curvature  (concave  posteriorly  or  anteriorly)  with  a 
considerable  degree  of  pes  equinus  results.     The  latter 


Fig.  151. — Fracture  of  the 
lower  end  of  the  bones  of  the  leg, 
with  large  oblique  anterior  tibial 
fragment,  and  small  posterior 
fragment. 


FRACTURES   OF    THE   LEG 


571 


does  not  always  affect  function  seriously,  and  may  even 
sometimes  he  useful  as  in  some  degree  compensating 
for  the  deformity  from  the  static  point  of  view,  but 
good  reduction  is  much  preferable.  There  is  almost 
always  some  degree  of  varus  or  valgus  also. 

Finally,  when  union  has  occurred,  there  is  usually 


Fig.  152. — Same  case  as  fig. 
151.  After  esquillectomy,  and 
fitting  a  continuous  extension 
apparatus  (plaster  with  Delbet's 
rods),  traction  is  still  inadequate, 
and  the  fracture  is  not  reduced. 


Fig.  153. — Final  result  after 
three  months  of  continuous  ex- 
tension. From  the  front  the 
reduction  seems  perfect.  Viewed 
laterally,  shght  rotation  forward 
is  still  evident. 


appreciable  shortening  and  deformity,  necessitating 
the  wearing  of  an  orthopaedic  boot. 

4.  Indications  for  early  Treatment.  —  The 
wound  must  be  disinfected  and  the  fracture  reduced. 

(a)  Disinfection  should  be  effected  as  soon  as  possible 
by  esquillectomy.  In  these  fractures,  however,  the 
splinters  are  not  numerous.  In  transverse  fractures 
two  incisions  re  made,  one  on  the  internal  aspect  of 
the  tibia,  and   he  other  over  the  fibula,  and  the  lateral 


572 


TREATMENT    OF    FRACTURES 


fragments  are  removed.  The  fibula  is  shortened  as 
may  be  necessary  by  sawing  off  enough  of  the  supra- 
articular  cancellous  tissue  to  reduce  it  to  corresponding 
dimensions  with  the  tibia.  When  the  fracture  has 
been  cleared  in  this  way,  its  posterior  aspect  is  ex- 
amined ;  it  is  not  unusual  to  find  smaE  spicules  of  bone 
here   which   must   be   removed  with  great   care.     In 


Fig.  154. — Infected  supra- 
malleolar fracture.  Radiograph 
after  total  sub-periosteal  es- 
quillectomy  on  the  fourth  day. 


Fia.  155. — Result  given  by 
continuous  extension  after  three 
months.  Fracture  united  by  a 
very  translucent  but  resistant 
callus. 


oblique  fractures,  part  of  the  tapering  extremity  of  the 
lower  fragment  must  be  removed,  in  order  to  expose 
the  region  well,  and  to  explore  it  thoroughly.  This 
has  not  appeared  to  me  to  facilitate  its  reduction. 

(6)  Reduction  is  very  difficult,  as  no  direct  hold  on 
the  lower  fragment  is  possible. 

At  first,  post-operative  manual  reduction  during 
anaesthesia  is  sufficient,  with  immediate  application  of 
plaster.  But  as  soon  as  possible  something  better 
must   be   done  :     continuous   extension   is   necessary, 


FRACTURES   OF    THE   LEG  573 

but  is  inadequate  if  applied  in  the  usual  way.  I  have 
often  exerted  the  pull  through  stirrups  incorporated  in 
the  dressing,  without  ever  succeeding  in  obtaining 
perfect  correction.  A  better  result  is  given  by  sus- 
pension, because  less  force  is  lost,  and  the  traction  is 
better  utilised.  Even  this,  however,  is  not  ideal. 
Without  experience  of  it,  I  am  inclined  to  believe  that 
extension  by  nail  transfixion  or  the  Finochietto  stirrup 
is  definitely  indicated.  The  danger  of  infection  will  be 
urged  against  this,  but  it  is  not  great,  and  the  danger 
of  non-reduction  is  certainly  more  urgent. 

5,  The  Treatment  of  cases  seen  at  a  late  stage 
OR  AFTER  PREVIOUS  TREATMENT. — (a)  A  case  has  done 
well  without  operation. — In  these  cases,  treatment 
should  be  directed  solely  to  reduction  and  immobilisa- 
tion. For  this  purpose  I  believe  the  best  apparatus 
to  be  a  suspension  appliance,  with  traction  by  means 
of  the  Finochietto  stirrup  (figs.  33-35). 

(b)  A  case  arrives  with  sepsis  in  the  secondary 
period: — Immediate  esquillectomy.  as  described  above, 
is  necessary  ;  it  should  be  comprehensive,  every  effort 
being  made  to  overlook  nothing.  Immobilisation 
should  be  based  on  the  same  principles. 

When  the  injury  to  soft  parts,  tendons,  muscles,  and 
skin  is  too  extensive,  amputation  may  be  justified,  not 
because  it  is  impossible  to  check  the  infection,  but 
because  a  deplorable  functional  result  is  to  be  antici- 
pated. Judgment  is  only  possible  in  individual  cases, 
and  it  is  impossible  to  give  a  definite  rule  on  the  subject. 

(c)  A  case  arrives  with  a  sinus. — Sometimes  this 
is  a  simple  matter,  and  the  removal  of  a  sequestrum  is 
sufficient  to  effect  cure.  But  much  more  often  ex- 
tensive clearance  of  the  tibia  is  necessary,  and  even 
actual  sub-periosteal  resections  of  the  shaft,  in  order 
to  bring  about  recovery. 

{d)  A  case  is  seen  with  equmus. — Some  cases  of  this 
sort  are  compensating,  and  no  interference  should  be 
attempted  ;    value  should  be  attached  in  these  cases 


374  TREATMENT    OF    FRACTURES 

rather   to   functional   usefulness   than   to   anatomical 
appearance. 

Sometimes,  when  there  is  vicious  or  painful  anky 
losis,  astragalectomy  is  indicated.  On  the  other  hand, 
this  has  little  effect  on  a  vicious  callus,  and  under  such 
circumstances  direct  operation  on  the  region  of  the 
fracture  is  preferable.  On  several  occasions  I  have 
performed  double  osteotomy  in  the  fractured  region, 
foUowed-by  osteosynthesis,  with  excellent  orthopaedic 
and  functional  results.  This  is  the  ideal  treatment  for 
a  vicious  callus. 

II.  Fracture  of  the  Tibia 

There  are  three  types  of  fracture  of  the  tibia  alone  : 
Fracture  of  the  upper  end. 
Fracture  of  the  shaft. 
Fracture  of  the  lower  end. 

A.  Extra-articular  Fracture  of  the  Upper  End. — This 
is  a  fracture  of  a  very  special  type.  The  super- 
ficial wound  is  small,  but  the  cancellous  tissue  is  ex- 
tensively crushed  by  the  projectile,  close  up  to  the 
articular  cartilage.  In  a  few  days  this  contused 
cancellous  tissue  undergoes  necrosis,  and  a  foul  form 
of  sepsis  develops  which  affects  the  joint ;  in  many 
cases  amputation  in  the  thigh  becomes  necessary. 

When  the  infection  is  less  violent,  a  chronic  suppura- 
tion develops,  with  slow  necrosis  and  gradual  elimina- 
tion of  the  cancellous  tissue,  which  frequently  ends  in 
ankylosis  of  the  knee  and  sinus-formation,  or  in 
pseudarthrosis. 

Sometimes  union  occurs,  but  it  is  then  almost  in- 
variably vicious,  the  lower  fragment  sliding  backwards 
upon  the  upper  and  producing  the  deformity  known  as 
a  "  bayonet  leg." 

Tn  short,  therefore,  this  is  a  serious  fracture.  It 
should  be  treated  by  early,  if  not  immediate,  removal 


FRACTURES  OF   THE  LEG  575 

of  all  contused  cancellous  tissue.  For  this  purpose,  the 
region  must  be  widely  exposed,  if  necessary  by  making 
a  crucial  incision,  and  freeing  with  a  rugine  the  peri- 
osteum into  which  the  patella  tendon  is  inserted  ;  the 
anterior  wall  of  the  fracture  area  is  removed,  and 
the  cancellous  tissue  carefully  cleaned  with  the  curette 
until  apparently  healthy  bone  is  encountered. 

After  this,  the  limb  is  immobilised  in  a  plaster  case 
which  presses  the  lower  fragment  forwards.  This 
arrangement  is  temporary  only,  and  should  be  replaced 
later  by  a  suspension  immobilisation  appliance  (see 
fig.  140).  Backward  rotation  of  the  lower  fragment 
is  thereby  prevented  by  excluding  muscular  action. 

The  same  treatment  should  be  adopted  as  a  secondary 
measure.  The  wound  should  then  be  left  widely  open, 
and  any  small  fragments  of  bone  remaining,  which  are 
usually  eliminated  by  degrees,  should  be  looked  for  ; 
if  necessary,  occasional  applications  of  the  curette  are 
made.  The  wound  should  then  progress  aseptically, 
but  the  healing,  and  the  filling-up  of  the  large  cavity 
excavated  in  the  cancellous  tissue,  must  be  closely 
attended  to.  Sometimes  the  latter  may  be  plugged, 
and  left  exposed  to  the  air  and,  particularly,  to  the 
sun.     Recovery  takes  three  to  four  months. 

A  sinus  is  treated  by  opening  up  widely ;  in  certain 
cases  a  large  cavity  will  be  found  in  the  epiphysis, 
and  resection  of  the  head  of  the  bone  will  be  necessary. 
The  cartilaginous  surface  of  the  femoral  condyles  is 
removed,  and  the  surfaces  of  the  femur  and  tibia  are 
nailed  together  as  after  a  typical  resection.  It  will  be 
necessary  to  cut  a  groove  in  the  external  condyle,  for 
the  head  of  the  fibula, 

Pseudarthrosis  necessitates  a  freshening  of  the  bone 
ends  in  the  case  of  the  tibia,  and  removal  for  adaptive 
purp'oses  in  the  fibula.  Fixation  of  the  fragments  of 
the  tibia  is  necessary  ;  I  have  twice  performed  it 
successfully  at  the  fistulous  stage. 

B,  Fractures  of  the   Shaft. — There  are   many  lateral 


576  TREATMENT    OF    FRACTURES 

wounds  of  the  tibia,  with  fissures  radiating  beneath  the 
periosteum,  but  with  no  true  fracture.  Complete 
fractures  without  injury  to  the  fibula  are  uncommon. 
The  fracture  is  hence  almost  always  one  with  large 
diamond-shaped  splinters,  more  or  less  disposed  in  the 
classical  "  butterfly- wing "  manner,  or  as  a  spiral 
fracture.  There  is  usually  very  little  displacement,  the 
fibula  being  intact. 

The  course  of  these  fractures  is  identical  with  that 
of  fractures  of  the  leg,  in  which  the  tibial  element  is 
much  the  more  important :  grave  infection,  acute 
osteomyelitis,  diffuse  cellulitis  of  the  calf,  and  later, 
chronic  osteomyelitis,  suppuration,  and  sinus-forma- 
tion. Owing  to  the  elimination  of  sequestra,  it  is 
not  unusual  to  see  union  fail  to  occur,  the  fibula  acting 
as  a  rigid  support,  and  keeping  the  fragments  of  the 
tibia  apart. 

The  first  step  is  free  esquillectomy,  the  periosteum 
being  preserved.  Subsequent  treatment  is  conducted 
as  already  described.  Immobilisation  is  effected  by  a 
simple  plaster  trough.  Any  extension  appliance  is 
useless,  because  the  fibula  is  intact. 

If  esquillectomy  has  left  an  appreciable  inter- 
fragmentary gap,  and  if  this  still  appears  considerable 
in  a  radiograph  after  three  or  four  weeks,  an  adaptive 
resection  of  a  sufficient  length  of  the  fibula  (|  to  1 
inch)  is  carried  out  as  a  precaution  to  prevent  pseud- 
arthrosis. 

C.  Fracture  of  the  Lower  End. — Isolated  fractures  of 
the  internal  malleolus  are  sometimes  seen,  with 
fissures,  and  often  detachment  of  splinters,  both 
involving  the  joint.  If  the  fracture  continues  aseptic, 
the  articular  lesion  is  unimportant.  If  the  infection 
is  superficial,  slight  arthritis  develops,  which  almost 
always  ends  in  ankylosis  of  the  ankle-joint.  Sometimes 
the  infection  is  deeper,  and  suppurative  arthritis 
develops  ;  this  is  exceedingly  rare,  and  the  cases  which 
are  being  discussed  here  should  be  clearly  distinguished 


FRACTURES   OF   THE  LEG  577 

from  definitely  articular  wounds,  complicated  by  a 
malleolar  fracture,  which  are  discussed  in  Part  I,  p.  242- 

In  isolated  fractures  of  the  tibial  malleolus,  limited 
esquillectomy  is  usually  sufficient  :  the  early  removal 
of  the  small  splinters  and  the  fragment  which  extends 
into  the  joint,  ensures  an  uneventful  development  of 
the  fracture.     Cure  is  complete  in  about  forty  days. 

On  the  whole,  this  fracture  is  not  a  severe  one. 

ni.    Fracture  of  the  Fibula 

Three  types  may  be  distinguished  in  practice  : 
Fracture  of  the  head  and  neck. 
Fracture  of  the  shaft. 
Fracture  of  the  malleolus. 

A.  Fractures  of  the  Head  and  Neck. — These  are 
generally  fractures  by  crushing  of  the  cancellous  tissue, 
with  one  or  two  small  compact  splinters  at  the  point  of 
junction  with  the  shaft. 

There  is  no  displacement,  in  spite  of  the  presence  of 
the  biceps  tendon,  but  the  external  popliteal  nerve  is 
frequently  involved. 

Being  very  superficial,  the  fracture  is  not  com- 
plicated by  serious  septic  conditions,  and  the  vicinity 
of  the  knee-joint  is  of  no  practical  importance.  But 
as  cancellous  tissue  is  concerned,  it  is  usual  for  osteitis 
to  continue  indefinitely,  delaying  a-  final  cure,  while 
the  infection,  giving  rise  to  the  formation  of  scar  tissue, 
reacts  seriously  on,  and  sometimes  causes  secondary 
paralysis  of,  the  neighbouring  external  popliteal  nerve. 
Cure  often  occurs  after  elimination  of  a  considerable 
part  of  the  bone,  but  the  loss  of  bone-substance  caused 
in  this  way  has  no  effect  on  equilibrium.  Prolonged 
suppuration,  however,  lays  up  the  patient  for  a  con- 
siderable period. 

It  would  therefore  appear  advisable,  as  soon  as  the 
case  has  been  examined,  to  perform  total  sub-periosteal 


578 


TREATMENT   OF  FRACTURES 


esquillectomy.  This  operation  need  only  be  a  re- 
section in  exceptional  cases  :  resection,  in  fact,  would 
inevitably  open  the  upper  tibio-fibular  joint,  and  this, 
in  about  12  per  cent,  of  cases,  communicates  with  the 
synovial  cavity  of  the  knee-joint.  A  risk  would  there- 
fore be  run,  which  it  is  better  to  avoid.     Esquillectomy 

is  performed  by  means  of 
an  incision  which  at  once 
exposes  the  external  popli- 
teal nerve,  in  order  to  safe- 
guard it  from  injury.  The 
incision  should  be  made,  not 
directly  over  the  bone,  but 
posterior  to  it,  along  the 
biceps  tendon,  which  forms 
an  obvious  prominence  be- 
neath the  skin.  The  incision 
is  begun  about  an  inch  above 
the  head,  and  directed  along 
the  bone  in  such  a  way  as 
to  correspond  with  the  inter- 
stice between  the  soleus  and 
the  peronei  muscles.  When 
protection  of  the  nerve  has 
been  ensured,  esquillectomy 
is  carried  out  as  usual,  with 
a  rugine. 

The   operation    over,    im- 
mobilisation for  a  few  days 
is  advisable,  without  plaster 
or  splint. 
The  subsequent  course  is  usually  uneventful  ;  treated 
in  this  way,  these  fractures  are  almost  featureless. 

B.  Fractures  of  the  Shaft. — ^Either  the  fracture  is 
comminuted,  or  it  has  short  fragments  and  radiating 
fissures.  Owing  to  the  laceration  of  neighbouring 
muscles,  this  very  simple  fracture  should  be  treated  as 
rigorously  as  any  other,  in  order  to  avoid  the  tracking 


Fig.  156. — Fracture  of  the 
fibula,  with  osteitis  of  the 
whole  head  of  the  bone,  and 
secondary  paresis  of  the 
external  popliteal .  nerve. 
Complete  secondary  resec- 
tion of  the  head  of  the  bone 
was  necessary. 


FRACTURES   OF   THE   LEG  579 

of  pus,  cellulitis  of  the  calf,  secondary  haemorrhages, 
etc.,  which  develop  when  any  wound  or  fracture, 
whatever  its  initial  appearance,  is  not  systematically 
cleaned.  Esquillectomy  should  therefore  be  performed 
at  once,  the  bone  being  exposed  by  an  external  incision 
over  its  prominence,  and  all  the  splinters  removed 
after  being  separated  from  the  periosteum.  A  careful 
search  is  made  for  the  smallest  fragments  of  bone, 
which  are  often  driven  into  the  calf  muscles  :  I  have 
several  times  found  them  between  the  peroneal  and 
posterior  tibial  vessels.  This  avoids  subsequent  vascu- 
lar complications,  which  otherwise  occur  frequently, 
and  the  simplicity  and  rapidity  of  healing  will  cause 
surprise.  I  have  seen  the  periosteum  form  a  column 
of  new  bone  uniting  the  two  fragments.  I  have  also 
seen  regeneration  fail  to  occur,  but  this  is  of  no  prac- 
tical importance. 

At  a  later  stage  the  same  methods  should  be  applied  : 
phlegmon  of  the  calf,  which  is  the  usual  evidence  of 
infection  of  the  fractured  region,  is  very  rapidly  checked 
by  these  means.  Unless  speedy  action  be  taken,  there 
is  prolonged  suppuration,  followed  by  lardaceous 
sclerosis  of  the  calf-muscles — with  secondary  equinus — 
necessitating  orthopaedic  corrections  at  a-  late  stage 
which  are  often  difficult.  In  pes  equinus  due  to 
muscular  contracture,  lengthening  of  the  tendo  Achillis 
by  a  Z-shaped  incision  gives  little  result  :  it  is  better 
to  shorten  the  skeleton,  and  adapt  it  to  the  muscular 
retraction  by  performing  astragalectomy.  Quite 
recently  I  have  performed  temporary  astragalectomy 
for  cases  of  this  kind,  sawing  through  the  bone  hori- 
zontally, and  immediately  replacing  the  upper  half  of 
it :  the  results  have  been  perfect  ;  the  movements  of 
the  ankle-joint  have  been  entirely  recovered,  and  the 
length  of  the  limb  has  only  been  reduced  by  half  an 
inch. 

C.  Fracture  of  the  Malleolus. — These  fractures  are 
usually  not  serious.     This  is  fortunate,  since  preserva- 


580  TREATMENT   OF  FRACTURES 

tion  of  the  external  malleolus  is  essential  for  the 
satisfactory  equilibrium  of  the  foot.  These  fractures 
should  be  clearly  distinguished  from  intra-articular 
fractures  of  the  astragalus  complicated  by  injury  to 
the  external  malleolus. 

The  limited  esquillectomy  which  is  necessary  is 
usually  sufficient  to  ensure  an  uneventful  course. 

If  there  is  slight  articular  infection,  simple  immobili- 
sation may  be  sufficient ;  but  there  should  be  no  hesita- 
tion in  doing  astragalectomy  in  the  event  of  an  acute 
septic  condition. 


CHAPTER  XVII 

MULTIPLE  FRACTURES  OF  THE  LOWER  LIBIB 

These  are  not  uncommon  :  they  call  for  rigorous 
application  of  the  principles  laid  down  for  each  variety 
of  fracture  considered  separately — that  is  to  say, 
immediate  sub-periosteal  esquillectomy,  primary  or 
secondary,  according  to  when  the  case  is  seen.  The 
necessity  for  esquillectomy  is  more  pressing  in  these 
complex  cases  than  in  any  others. 

The  only  really  difficult  problem  presented  by  these 
fractures  is  that  of  immobilisation.  Temporarily,  and 
as  an  appliance  for  transport,  plaster  is  the  best 
medium ;  but  as  soon  as  possible,  recourse  should  be 
had  to  a  suspension  appliance,  either  extending  the 
entire  lower  limb,  or,  better,  arranging  the  thigh  in 
flexion  on  the  pelvis,  and  the  leg  in  flexion  on  the  thigh. 
It  is  easy  in  the  latter  case  to  apply  a  double  extension, 
one  to  the  thigh  and  the  other  to  the  leg  (see  fig.  142). 

Double  fractures  of  a  hone  should  be  treated  on  similar 
lines,  and  a  useful  limb  can  be  preserved  by  esquil- 
lectomy even  in  the  most  complex  cases.  I  have 
personally  treated  and  cured  a  double  fracture  of  the 
femur  by  double  sub-periosteal  esquillectomy,  and  a 
bipolar  fracture  of  the  bones  of  the  leg  by  resection  of 
the  knee  above  and  esquillectomy  below.  The  case 
was  cured  with  a  shortening  of  2|  inches. 


SECTION  II 

FRACTURES  OF  THE 
LOWER  JAW 


FRACTURE  OF  THE 
LOWER  JAW 

CHAPTER    I 

INTRODUCTION 

The  study  and  therapeutics  of  fracture  of  the  mandible 
are  not,  in  their  inception,  the  outcome  of  the  war. 
It  cannot  be  denied,  however,  that  our  knowledge  of 
the  subject  has  been  greatly  advanced  and  consoli- 
dated by  the  vast  amount  of  clinical  material  which 
has  come  under  observation  since  the  outbreak  of  war. 
The  writings  and  research-work  of  Claude  Martin  had 
previously  provided  a  source  of  knowledge  of  the  most 
fundamental  kind,  but  the  literature  of  the  subject, 
with  this  exception,  was  mainly  bibliographic  in 
character,  no  surgeon  or  stomatologist  at  that  time 
possessing  personal  experience  of  any  great  value. 
Claude  Martin  alone,  by  his  patient  investigations  and 
his  undeniable  genius,  was  able  to  evolve  the  basic 
principles  of  this  branch  of  surgical  science. 

But  even  he  was  able  to  bring  together  only  a  com- 
paratively  limited  number  of  facts.  His  observations 
were  largely  founded  upon  the  operative  results  of 

585 


580  INTRODUCTION 

resection  of  the  mandible,  valuable  clinical  material 
being  contributed  by  Oilier.  His  knowledge  of  frac- 
tures was,  however,  unfortunately  confined  to  the 
few  cases  which  in  normal  peace-time  come  under 
observation.  Not  only  are  such  cases  comparatively 
rare,  but  they  are  observed  under  the  most  favourable 
conditions,  loss  of  substance  being  an  infrequent  com- 
plication. Claude  Martin's  investigations  are  already 
ancient  history,  and  since  his  day  the  methods  of 
cHnical  procedure,  especially  in  the  domain  of  surgery, 
have  become  transformed,  and  it  is  obvious  that  the 
results  to  which  they  lead  must  also  be  very  much 
modified. 

One  of  the  most  unexpected  revelations  of  the 
surgery  of  the  war  is  the  small  number  of  fatal  results 
in  wounds  of  the  face.  If  we  exclude  those  cases  in 
which  there  is  severe  haemorrhage  or  in  which  the 
general  condition  is  bad,  cases  which  never  reach  a 
base  hospital,  the  mortality  is  extraordinarily  low. 
The  present  generation  of  surgeons  has  been  brought 
up  in  the  wholesome  dread  in  these  cases  of  septic 
comphcations,  such  as  pyaemia  of  buccal  origin,  and 
septic  broncho-pneumonia,  conditions  whose  occurrence 
one  would  naturally  expect  in  cases  where  there  is 
great  difficulty  in  feeding  the  patient.  Statistics 
derived  from  every  centre  of  treatment,  however,  show 
entirely  favourable  results.  The  mortahty  barely 
reaches  1  per  1,000,  and  is  frequently  lower.  Monthly 
reports  from  the  surgeons  in  charge  of  these  centres 


INTRODUCTION 


587 


show  that  their  work  is  practically  confined  to  the 
restoration  of  function,  life  in  any  case  being  assured. 
It  is  not  surprising  that,  under  the  present  con- 
ditions, technical  research  has  attained  a  development 
and  yielded  results  which  were  undreamt  of  before 
the  outbreak  of  war.  In  those  past  days  a  fractured 
mandible  was  a  serious  matter.  Few  civiHan  surgeons 
had  any  practical  experience  of  the  various  appUances 


Fig.  1. — ^Normal  dental  "adjustment  seen 
in  the  horizontal  plane.  The  inferior^arch 
articulates  within  the  superior  arch,  the 
inferior  median  teeth  being  behind  the 
superior  median  teeth,  and  the  inferior 
lateral  teeth  inside  the  corresponding  teeth 
of  the  upper  jaw.  (iThe  inferior  teeth  are 
indicated  by  means  of  dotted  lines.) 


Fig.  2.  —  Normal 
dental  adjustment 
viewed  in  the  vertical 
plane.  The  posterior 
two-thirds  of  the  in- 
ferior molars  corre- 
sponds to  the  anterior 
two-thirds  of  the  corre- 
sponding teeth  of  the 
upper  jaw, 

recommended  by  the  text-books,  appliances,  moreover, 
which  were  largely  unobtainable.  In  later  years,  how- 
ever, dentists  were  appointed  to  the  hospitals  in  most 
of  the  larger  towns,  and  where  these  worked  in  colla- 
boration with  the  surgeons  better  results  were  obtained, 

1  Emphasis  is  laid  upon  the  fact  that  these  favourable  results 
depend  upon  the  exclusion  of  hopeless  cases,  such  as  do  not  leave 
tho  first  dressing  stations. 


588  INTRODUCTION 

though  even  here  the  paucity  of  clinical  material  stood 
in  the  way  of  both  surgeon  and  dentist. 

Before  entering  upon  a  detailed  description  of  frac- 
tures of  the  mandible  it  is  advisable  to  enumerate 
certain  physiological  peculiarities  of  this  bone,  which 
differs  considerably  from  those  upon  which  surgeons 
are  usually  required  to  operate.  The  minuter  details  of 
the  movements  of  mastication  need  not  detain  us  here  ; 
it  will  suffice  to  describe  them  on  broad,  general  Unes. 

Mastication  can  only  be  performed  when  the  upper 
and  lower  teeth  are  in  normal  occlusion  with  one 
another.  Their  position  in  regard  to  one  another  is 
shown  b}^  figs.  1  and  2,  which  illustrate  respectively 
the  horizontal  and  vertical  planes.  Fig.  1  shows  that 
the  position  of  the  mandibular  dental  arch  is  within 
that  of  the  maxilla,  the  mandibular  median  teeth 
being  behind  the  maxillary  median  teeth  and  the 
mandibular  lateral  teeth  within  the  corresponding 
teeth  of  the  maxilla.  Fig.  2  shows  that  the  maxillary 
teeth  are  slightly  superimposed,  in  such  a  way  that 
the  mandibular  first  molar  articulates  with  the  anterior 
portion  only  of  the  corresponding  tooth  of  the  maxilla, 
one-third  of  its  surface  being  in  contact  with  the  max- 
illary second  premolar.  The  combination  of  these 
relationships  constitutes  what  is  known  to  dentists  as 
the  "  dental  articulation  "  (occlusion  of  the  teeth).  To 
avoid  confusion  in  terminology,  however,  we  propose 
throughout  this  book  to  employ  the  term  "  dental 
adjustment." 


INTRODUCTION  ^H!) 

Efficient  mastication  is  dependent  upon  normal 
dental  adjustment,  and  the  ideal  method  is  to  preserve 
it.  Rigidity  of  the  mandible  is,  however,  of  equal 
importance,  for  it  is  evident  that,  once  this  rigidity  is 
lost,  the  power  of  the  mandible  is  reduced  by  half, 
for  each  fragment  is  subject  to  the  action  of  one  only 
of  two  sets  of  muscles.  A  condition  of  instability  is 
thus  established  which  still  further  impedes  the  masti- 
catory function. 

Dental  adjustment  and  mandibular  rigidity  are  the 
fundamental  conditions  aimed  at  in  the  treatment  of 
fractures  of  the  lower  jaw.  Fracture  by  projectiles  is, 
however,  almost  invariably  accompanied  by  loss  of  sub- 
stance, and  the  surgeon  finds  that  he  is  faced  with  a 
choice  between  two  evils.  To  preserve  the  adjustment 
the  fragments  must  remain  apart,  with  consequent 
pseudo-arthrosis.  To  obtain  rigidity  the  fragments 
must  be  brought  together,  with  consequent  disturbance 
of  adjustment.  In  certain  cases,  as  will  be  shown  later, 
it  is  possible  to  avoid  both  evils,  but  in  the  majority 
of  instances  the  surgeon  is  compelled  to  make  a 
choice. 

Claude  Martin  was  inflexibly  in  favour  of  the  pre- 
servation of  dental  adjustment,  and  it  seems  certain 
that  in  no  case  was  he  willing  to  sacrifice  it  in  order  to 
obtain  rigidity  of  the  bone.  His  views  were  un- 
doubtedly influenced  by  the  nature  of  the  cases  which 
passed  through  his  hands.  In  his  experience  loss  of 
substance  was  mainly  the  result  of  surgical  inter- 
vention, and,  the  tissue  removed   being   almost   in- 


590  INTRODUCTION 

variably  morbid,  economy  in  its  jemoval  would  have 
been  misplaced.  Under  these  circumstances  there 
would  have  been  little  wisdom  in  seeking  to  effect  a 
union  which,  had  it  been  practicable,  must  have  been 
'imperfect.  This  is  no  doubt  the  explanation  of  Claude 
Martin's  adherence  to  the  maintenance  of  adjustment. 
His  method  was,  by  means  of  an  apparatus,  to  preserve 
the  spacing  of  the  teeth  as  it  existed  before  operation. 
Not  only  did  he  not  obtain  rigidity,  but  the  presence 
of  the  apparatus  itself  largely  militated  against  it. 

Experience  in  a  large  number  of  cases  of  maxillo- 
facial mutilation  has  led  us  to  abandon  Claude  Martin's 
principle  in  its  entirety  and  to  sacrifice  dental  adjust- 
ment to  bony  rigidity.  That  pseudo-arthrosis  consti- 
tutes a  grave  functional  defect  cannot  be  denied  ;  that 
it  is  not  susceptible  to  correction  by  means  of  an 
apparatus  will  be  shown  later.  Our  cases  differ,  of 
course,  very  considerably  from  those  of  Claude  Martin  ; 
we  have  to  deal  with  extensive  loss  of  substance,  and 
pseudo-arthrosis  is  frequently  inevitable.  Experi- 
ments in  bone-grafting  haVe  been  attempted,  and  this 
method  may,  at  a  later  date,  yield  favourable  results. 
There  is,  however,  a  large  class  of  patients,  perhaps 
the  largest,  in  whom  the  loss  of  substance  does  not 
exceed  two  or  three  centimetres.  In  all  these  cases 
rigidity  is  obtainable  either  by  means  of  an  apparatus 
or  by  surgical  means.  In  either  event  the  fragments 
must  be  brought  together,  with  consequent  disturbance 
of  adjustment.  In  our  opinion  the  diminution  of 
function  is  more  than   compensated  by  the  benefit 


INTRODUCTION  591 

which  these  patients  derive  from  the  rigidity  of  their 
lower  jaw. 

Where  the  loss  of  substance  is  small,  the  disturbance 
of  adjustment  is  practically  inappreciable  ;  up  to  one 
centimetre  it  appears  to  be  negligible.  Where  there 
is  a  gap  of  two  or  three  centimetres  the  case  is  different, 
but  even  here  the  error  in  adjustment  is  largely  re- 
ducible. It  is  possible  to  confine  the  error  to  one 
fragment  only,  and  that  the  smaller  ;  to  arrange  in 
fact,  in  a  manner  which  will  be  described  later,  that  it 
shall  bear  the  entire  brunt  of  the  displacement.  The 
larger  portion,  that  which  contains  the  greater  number 
of  teeth,  remains  in  perfectly  normal  accord  with  the 
maxilla.  Thus  the  disturbance  of  adjustment  affects 
only  a  small  portion  of  the  jaw,  and,  owing  to  the 
vicinity  of  the  site  of  fracture,  it  is  usually  in  this 
portion  that  the  greater  number  of  teeth  are  missing. 
Indeed,  it  frequently  happens  that  the  posterior 
fragment  does  not  contain  a  single  tooth,  and  the  dis- 
turbance of  adjustment  thus  becomes  purely  theoretical, 
all  the  teeth  present  being  in  perfect  occlusion. 

To  appreciate  the  advantage  of  this  method,  it  is 
only  necessary  to  compare  the  condition  of  a  patient 
whose  mandible  is  rigid  with  that  of  one  suffering  under 
the  disabilities  of  pseudo-arthrosis.  The  former  re- 
quires merely  an  apparatus  containing  a  few  artificial 
teeth,  and,  more  often  than  not,  he  is  content  to 
masticate  upon  the  sound  side  of  his  jaw.  His  con- 
dition is  practically  normal,  and  it  is  not  necessary  to 
j^ive  him  hi^s  discharge.     The  second  class  of  patient 


592  INTRODUCTION 

is  in  a  very  different  position.  He  is  furnished  with 
a  corrective  mechanism  which  is  indispensable  to  his 
existence.  Even  with  this  aid  his  mastication  is  so 
imperfect  that  it  is  necessary  to  discharge  him  with  a 
grant,  or  even  with  a  pension. 

It  has  seemed  to  us  imperative  that  this  question 
of  method  should  be  clearly  stated  from  the  outset. 
We  feel  that  the  case  for  mandibular  rigidity  in  pre- 
ference to  dental  adjustment  has  been  proven,  and 
that,  as  we  shall  show  later,  in  the  vast  majority  of 
cases,  it  constitutes  the  only  sound  therapy. 

The  movements  of  the  mandible  are  effected  by 
means  of  the  two  temporo-mandibular  joints.  These 
are  extremely  complex,  and,  in  addition  to  movements 
of  elevation  and  depression,  they  effect  also  movements 
of  projection  and  retraction.  They  possess  a  specific 
solidarity,  each  joint  being  incapable  of  action  without 
the  other.  In  the  same  way  that  torsion  of  the  fore- 
arm is  possible  only  when  the  interlines  of  both  elbow 
and  wrist  are  intact,  so  depressor  movements  of  the 
mandible  are  suppressed  by  ankylosis  of  one  or  other 
of  the  mandibular  joints,  immobilisation  of  the  entire 
bone  resulting  from  a  unilateral  lesion.  Cases  of  this 
sort,  though  rare,  are  not  unknown. 

On  the  other  hand,  the  duplicate  articulation  of  the 
mandible  carries  with  it  certain  very  decided  ad- 
vantages. These  joints  are  so  strong  that  the  clench- 
ing capacity  of  the  teeth  amounts  literally  to  a  feat  of 
strength.     Their  configuration,  moreover,  permits  of 


INTRODUCTION  593 

certain  displacements  which  may  become  permanent 
without  in  any  essential  particular  affecting  their 
sohdity.  Dentists  are  able,  \^'ith  comparative  ease,  to 
manipulate  the  jaw  in  such  a  way  that  the  whole  of  the 
lower  row  of  teeth  is  brought  shghtly  forward,  and  this 
position  can  be  rendered  permanent.  This  manoeuvre, 
which  is  known  as  "  jumping  the  bite,"  is  obviously 
dependant  upon  the  play  of  the  two  articulations. 

The  number  and  variety  of  the  movements  which  it 
is  able  to  effect  lend  to  the  mandible  a  peculiar  physio- 
logical interest.  It  possesses  yet  another  quality 
which,  to  the  surgeon,  is  of  even  greater  value,  namely, 
its  capacity  for  immobilisation.  This  is  greater  than 
that  of  any  other  bone  in  the  body.  By  attaching  an 
arch  with  studs  to  each  row  of  teeth  and  firmly  ligatur- 
ing the  two  arches  together  with  brass  wire,  the  jaw 
becomes  absolutely  immobilised.  It  is  this  capacity 
for  complete  immobilisation'  which  renders  possible 
the  rapid  consolidation  of  fractures;  even  those  in 
which  the  loss  of  substance  is  comparatively  extensive. 
More  important  still,  the  apparatus  for  immobilisation, 
though  it  debars  mastication,  does  not  prevent  feeding. 
Liquids  can  readily  pass  through  the  dental  inter- 
stices, the  retromolar  space,  or  through  the  gaps 
left  by  teeth  which  have  been  lost.  As  a  matter  of 
fact  there  are  few  patients  who  are  content  ^\\t\\  a 
liquid  diet  ;  they  usually  manage  to  consume  crumb 
of  bread,  purees  of  all  kinds,  minced  meat,  etc. 


594  INTRODUCTION 

The  mandible  possesses  yet  other  surgical  advan- 
tages. In  the  case  of  a  broken  femur,  for  instance,  it 
is  not  ea&y  to  operate  directly  upon  the  fragments 
without  having  recourse  to  an  appliance  such  as  a 
screw  plate,  Lambotte's  splint,  Lambret's  apparatus, 
etc.  The  mandible  is  more  amenable  to  treatment. 
The  ceeth  present  points  of  attachment  which  are  ex- 
ceptionally easy  of  negotiation,  and,  where  the  crowns 
are  gone,  the  roots  are  probably  still  good.  Thus,  in 
addition  to  immobilisation,  the  surgeon  is  able  to  effect 
an  almost  mathematical  reduction  of  the  fracture.  In 
the  case  of  a  fractured  limb,  length  alone  can  be 
estimated  with  any  degree  of  exactitude  ;  other  devia- 
tions, such  as  the  angular,  the  rotatory,  can  only  be 
approximately  estimated.  In  the  case  of  the  mandible, 
a  perfect  and  incontestable  basis  is  provided  by  the 
dental  adjustment.  It  may  happen,  however,  that  the 
teeth  are  missing.  Occasionally  they  are  entirely  de- 
stroyed by  the  nature  of  the  injury  ;  sometimes  the 
roots  are  so  broken  that  extraction  is  the  only  possible 
course  ;  or  they  may  have  been  previously  destroyed 
by  dental  caries.  Finally,  it  may  happen  that  the  line 
of  fracture  passes  beyond  that  part  of  the  jaw  which 
contains  the  teeth.  Conditions  such  as  these  are  very 
difficult  to  deal  with,  and  they  tax  to  the  full  the  powers 
of  both  surgeon  and  specialist. 

As  we  shall  have  occasion  to  show  later  on,  the 
fragments  of  a  fractured  mandible  do  not,  so  far  as  we 
have  been  able  to  judge,  present  the  phenomena  of  a. 


INTRODUCTION  ^^^ 

rarefying  osteitis  so  frequently  observed  in  fracture 
of  the  bones  of  the  limbs .  In  both  kinds  of  case  pseudo- 
arthrosis is  frequent.  In  the  management  of  fractures 
of  the  bones  of  the  limbs,  lack  of  resistance  of  the 
fractured  parts  constitutes  one  of  the  chief  difficulties. 
Their  consistency  is  sometimes  so  attenuated  that  it 
is  not  possible  to  keep  a  metal  plate  in  position  by 
means  of  screws.  It  is  necessary  to  attach  it  by 
means  of  ligatures,  a  far  less  efficacious  method. 
This  is  a  difficulty  with  which,  in  the  case  of  the  man- 
dible, we  have  never  had  to  contend.  It  seems  rather 
that  the  extremities  of  the  fragments  undergo  a  species 
of  condensation.  The  retention  of  properly  adjusted 
screws  has  been  perfect  in  the  patients  upon  whom  we 
have  operated. 

Such  are  the  general  considerations  which  we  desire 
to  present  to  those  of  our  readers  who  are  unfamihar 
with  the  methdds  and  results  of  stomatological  thera- 
peutics. That  this  volume  contains  so  few  references 
to  the  name  of  Claude  Martin  may  to  such  readers 
appear  surprising.  It  is  not  that  we  fail  to  appreciate 
the  great  achievements  of  the  venerable  scientist,  who 
was  a  pioneer  at  a  date  when  there  was  some  merit  in 
being  one.  But  we  feel  that  of  his  work,  which  was 
largely  therapeutic,  very  little  ought  to  be  preserved. 
It  could  hardly  be  otherwise,  seeing  that  in  the  last 
quarter  of  a  century  surgical  methods  have  undergone 
a  complete  transformation,  while,  in  the  last  two  and 
a  half  years,  an  abundance  and  variety  of  cHnical 


59()  INTRODUCTION 

material  has  come  to  hand  such  as  Claude  Martin 
never  dreamt  of.  As  we  have  already  shown,  his 
fundamental  principle  has  not  stood  the  test  of  facts. 
His  object  at  all  costs,  even  that  of  pseudo-arthrosis, 
was  to  preserve  the  dental  adjustment.  We  have 
always  supported  the  opposite  view,  namely,  that  in 
the  vast  majority  of  cases  union  of  the  fracture  is  the 
more  important  aim.  Claude  Martin's  formula  was  : 
dental  adjustment  before  mandibular  rigidity.  Our 
formula  is  :  mandibular  rigidity  before  dental  adjust- 
ment. This  view,  which  we  were  the  first  to  advance, 
is  the  one  adopted  by  the  majority  of  surgeons  and 
stomatologists. 

But  although  the  details  of  Claude  Martin's  worl< 
are  becoming  effaced  by  time,  our  admiration  for  thi 
man  who,  first  of  all,  perceived  the  necessity  for  thi 
collaboration  of  the  surgeon  with  the  specialist  mus 
remain.  Claude  Martin  was  the  first  to  face  tht 
problem  of  the  re-establishment  of  the  masticator^/ 
function  after  surgical  intervention. 


CHAPTER    II 

ETIOLOGY 

Fractures  of  the  mandible  by  instruments  of  war 
are  usually  comminuted.  As  a  general  rule  they  differ 
from  those  observed  in  civil  life  by  loss  of  substance. 
It  is,  however,  by  no  means  exceptional  to  encounter 
war  fractures  in  which  there  is  no  loss  of  substance, 
the  injuries  closely  resembling  those  observed  in 
civiHan  practice. 

The  etiology  of  the  majority  of  cases  is  simple.  The 
mandible  is  struck  by  a  projectile  which  fractures  it, 
producing  fragments  of  varying  size,  which  are  either 
carried  away  by  the  projectile  or  are  eliminated 
secondarily  at  the  sequestration  stage.  It  may  happen, 
however,  that  the  mandible  is  struck  by  a  spent  pro- 
jectile, the  force  of  which  is  exhausted  by  the  shock 
of  contact.  In  such  a  case  the  mandible  is  fractured, 
but  either  not,  or  only  very  sUghtly,  spHntered.  In- 
juries of  this  nature  we  propose  to  describe  as  "  frac- 
tures by  contact,"  using  the  term  in  the  sense  in  which 
it  is  employed  to  denote  certain  fractures  of  the 
cranium.  In  this  class  of  case  there  is  no  loss  of 
substance  either  primary  or  secondary,  and  the  dis- 
placement is  generally  slight.     Apart  from  the  wound 

597 


59  8       FRACTURE  OF   THE  LOWER  JAW 

there  is  nothing  to  distinguish  these  cases  from  those 
seen  in  general  practice.  The  wound  itself  is  unim- 
portant, and  cicatrises  readily  in  spite  of  the  presence 
of  the  projectile,  whether  a  fragment  of  shell  or  a  bullet. 
It  should  be  borne  in  mind  that  the  accidents 
incidental  to  civihan  Hfe  are  not  aboKshed  in  time  of 
war.  Fracture  may  be  due  to  the  kick  of  a  horse,  a 
fall,  an  earthsUde,  etc.  In  such  cases  the  skin  is 
unbroken,  and,  were  it  not  for  the  injury  to  the  mucosa, 
which  is  usually  sHght,  the  fracture  would  be  a  simple 
one. 


CHAPTER    III 

PATHOLOGICAL   ANATOMY 

In  a  former  work  {Presse  Medicale,  25,  x.  1915)  we 
divided  the  fractures  of  the  mandible  into  two  main 
classes : 

1.  Anterior  fractures,  the  site  occupying  the  median 
hne  or  its  vicinity  ; 

2.  Posterior  or  lateral  fractures,  situated  within  a 
space  bounded  by  the  median  line  or  its  vicinity  on  the 
one  hand  and  the  angle  of  the  mandible  on  the  other. 

To  these  two  groups  we  propose  now  to  add  a  third, 
namely,  fractures  of  the  vertical  portion  or  ascending 
ramus  of  the  jaw.  The  distinction  may  be  regarded 
as  a  fine  one,  but  we  are  of  the  opinion  that  it  has  a 
definite  clinical  and  anatomical  value.  Fractures  of 
the  angle  of  the  jaw  resemble  those  included  in  group 
two,  with  this  reservation,  that  they  are  invariably 
characterised  by  absence  of  teeth  in  the  posterior 
fragment.  Finally,  there  are  cases  of  multiple  and 
of  comminuted  fracture. 

The  basis  of  classification  is  by  no  means  purely 
anatomical.  Each  of  the  main  groups — namely, 
anterior  fracture,  posterior  and  lateral  fracture, 
fracture  of  the  ramus — possesses  distinct  cUnical 
prognostic,  and  therapeutic  characteristics. 

599 


600      FRACTURE  OF   THE  LOWER  JAW 

The  amount  of  substance  lost  varies  considerably 
in  each  class,  A  loss  of  1  to  2  cm.  does  not  appreciably 
affect  either  the  clinical  appearances  or  the  prognosis. 
Where  the  loss  is  large,  however,  very  different  con- 
ditions obtain,  and  these  will  be  discussed  later. 

In  all  groups,  both  principle  and  secondary  (fracture 
of  the  angle,  multiple  fracture),  the  continuity  of  the 
bone  is  broken  and  the  fracture  is  described  as  "  com- 
plete." In  the  case  of  the  first  two,  fracture  occurs 
between  two  groups  of  masticatory  muscles.  In  the 
case  of  the  third,  it  affects  a  portion  of  bone  to  which 
one  group  of  these  muscles  is  attached.  Hence  the 
functional  derangement  consequent  upon  fracture  of 
one  of  the  rami  is  not  only  different  in  character,  but 
it  is  less  grave. 

In  addition  to  these  fractures,  which,  as  they  divide 
the  bone  into  two  parts,  are  termed  "  complete,"  there 
is  yet  another  variety,  obviously  of  minor  importance, 
namely,  the  "incomplete"  fracture.  We  propose  to 
deal  with  this  first. 


I.    Incomplete  Fracture 

Incomplete  fracture  does  not  interrupt  the  con- 
tinuity of  the  bone,  though  it  may  affect  any  part  of  it. 

Fracture  of  the  teeth  is  very  frequent,  and  is  usually 
a  complication  of  complete  fracture.  Artificial  re- 
placement is  the  only  method  of  dealing  with  the 
condition.  It  should  be  borne  in  mind  that  fractured 
roots  do  not  unite,  and,  even  where  a  tooth  appears 


PATHOLOGICAL  ANATOMIT  601 

to  be  sound,  if  the  root  is  cracked,  extraction  is  the  only 
remedy. 

Fracture  of  the  alveolar  border  is  common,  and 
occurs  frequently  as  a  complication.  There  is  a 
tendency  on  the  part  of  the  marginal  fragment  to  bend 
inwards,  probably  as  the  result  of  attempts  at  mastica- 
tion. Whether  these  fractures  come  under  treatment 
or  not,  they  invariably  unite,  with  the  consequent 
danger  of  malposition  bringing  the  chewing  surfaces 
of  the  maxillary  molars  over  the  external  surfaces  of 
the  mandibular  molars.  At  the  beginning  of  the  war 
such  deformities  were  frequent.  Now,  however,  that 
there  is  better  provision  for  treatment  they  are  rarely 
seen. 

Fracture  of  the  inferior  border  has  little  practical 
significance.  Its  presence  is  usually  revealed  by  small 
detached  sphnters  of  bone  which  either  unite  or  become 
sequestra. 

Fracture  of  the  coronoid  process  is  very  difficult  of 
observation,  and  skiagrams  give  httlc  help.  The  ap- 
pearances resemble  those  of  closure  of  the  jaws. 

Fracture  of  the  temporo-mandibiUar  joint  is  frequent 
and,  the  site  of  injury  being  immediately  beneath  the 
skin,  it  is  easy  of  diagnosis.  A  patient  who  came 
under  observation  had  in  his  possession  the  head  and 
neck  of  the  condyle,  which  had  been  eliminated  as  a 
sequestrum.  He  was  able  to  perform  masticatory 
movements  without  inconvenience.  Closure  of  the 
jaw  as  the  result  of  ankylosis  suggests  itself  as  a  very 
possible  compUcation,  yet  up  to  now  no  case  has  come 


(>02      FRACTURE  OF  THE  LOWER  JAW 


under  observation.  Except  that  lateral  deviation  and 
retrusioh  are  more  marked,  the  displacement  of  the 
fragments,  where  present,  is  precisely  similar  to  that 
observed  in  fracture  of  the  ramus. 

Perforation   is   sometimes  observed.      In  this  case 

the  projectile, 
usually  a  bullet, 
traverses  the  man- 
dible without  dis- 
turbing its  con- 
tinuity and  pro- 
duces a  simple 
loss  of  substance. 
It  is  noticeable 
that,  as  in  frac- 
tures of  the  cra- 
nium, the  inner 
bony  layer  is  mpre 
extensively  affected  than  the  outer,  with  the  result 
that  the  sequestra  are  sometimes  larger  than  the 
apparent  loss  of  substance.  The  analogy,  however, 
ceases  here,  these  lesions  having  none  of  the  gravity 
and  urgency  associated  with  those  of  the  cranium. 

II.    Complete  Fracture 

As  we  have  seen,  it  is  expedient  to  divide  th^  com 
plete  fractures  into  three  main  groups. 

Loss  of  substance  is  usual,  but  certain  fractures 
occur  which,  as  in  the  case  of  the  cranium,  we  propose 
to  describe  as  fracture  "by  contact,"  which  are  con- 


Fig.  3. — Different  types  of  incomplete 
mandibular  fracture  ;  fracture  of  the  upper 
or  alveolar  border ;  fracture  of  the  lower 
border ;  fracture  of  the  coronoid  process ; 
fracture  of  the  condyle  ;  perforation. 


PATHOLOGICAL  ANATOMY  603 

fined  to  a  simple  crack.  It  must  not  be  forgotten  that, 
among  the  casualties  of  war,  patients  cqme  under 
treatment  with  injuries  resembhng  those  seen  in 
civilian  practice,  the  originating  cause  being  not  a 
projectile,  but  a  landslide,  a  kick  from  a  horse,  etc. 
The  skin  in  these  cases  is  frequently  unbroken. 

(a)  Anterior  fracture  (median  or  paramedian). — 
The  position  of  the  fracture  site  is  sometimes  exactly 
median,  that  is  to  say,  it  passes  between  the  two 
median  incisors.  It  then  deviates  more  or  less  to 
either  the  right  or  left,  and  a  small  triangular  portion 
of  bone  is  frequently  detached  from  the  lower  border. 
In  some  cases  the  line  of  fracture  passes  between  the 
two  lateral  incisors  or  between  the  lateral  and  the 
canine.  In  any  event  the  displacement  of  fragments 
is  so  similar  that  the  types  are  easily  included  in  one 
group. 

In  median  or  paramedian  fracture  without  loss  of 
substance  the  deformity  is  so  shght  that,  unless 
attention  is  drawn  to  it,  the  lesion  may  pass  un- 
noticed. There  is  occasionally  a  sHght  vertical  dental 
error,  but  as  a  general  rule,  and  particularly  where  the 
fracture  is  single,  there  is  no  displacement  in  the  hori- 
zontal direction.  The  vertical  error  usually  undergoes 
spontaneous  correction  by  contact  with  the  upper  row 
of  teeth,  and  this  class  of  fracture  shows  a  distinct 
tendency  to  unite  spontaneously  in  good  position.  It 
is  fractures  of  this  nature  which  are  most  frequently 
encountered  in  civil  Ufe,  and  this  accounts  for  the  fact 
that, in  spite  of  the  inefficiency  of  the  retentive  measures 


604      FRACTURE  OF  THE  LOWER  JAW 

in  general  employment  before  the  war,  treatnnmt  of 
mandibular  fracture  was  not  entirely  unsuccessful. 

In  the  surgery  of  war,  however,  loss  of  substance  is 
almost  invariably  present,  and,  in  the  simplest  cases, 
it  corresponds  to  the  loss  of  one  or  two  teeth. 

Let  us  take  a  typical  instance  (fig.  4).     The  missing 


Fig.  4. — Anterior    median    fracture.     Loss    of    bony    substance 
equal  to  two  incisors. 

portion  of  bone  includes  the  two  median  incisors,  and 
the  loss  of  substance  amounts  to  1  cm.  The  two 
fragments  tend  to  approach  one  another.  As  they  are 
of  practically  the  same  length,  and  are  subject  to  very 
much  the  saine  influences,  each  portion  performs  half 
the  journey,  the  fractured  surfaces  again  meeting  at  the 
median  hne  (fig.  5).  The  effect  upon  the  interdental 
articulation  will  be  described  in  detail  later.     Suffice 


PATHOLOGICAL   ANATOMY 


C05 


it  here  to  say  that  in  cases  of  this  sort  the  derangement 
is  very  sHght,  the  effect  upon  the  molars  being  prac- 
tically nil.  It  is  more  apparent  in  the  case  of  the 
anterior  teeth,  where  the  natural  tendency  to  retreat 
behind  the  corresponding  teeth  of  the  upper  jaw  is 
intensified  (fig.  8). 

Where  loss  of  substance  is  very  extensive,  this  cannot 


FiG.  5.  —Displacement  of  fragments  in  the  fracture  shown  in 
lig.  4.  The  union  of  the  fractured  surfaces  produces  a  Gothic  arch, 
the  niandible  assuming  the  characteristic  serpent-form. 


of  course  hold  good.  There  is  always  a  tendency  on 
the  part  of  the  fractured  portions  to  approach  one 
another,  but  the  mandible  here  takes  on  a  triangular 
form  (Sebileau's  serpent  jaw)  which  not  only  throws 
the  front  teeth  very  much  behind  those  of  the  upper 
jaw,  but  also  produces  error  in  the  molar  articulation, 
\Y\i\\  consequent  functional  deficiency. 


Fig,  6. — Right  paramedian  fracture  with  moderate  loss  of  sub- 
stance. 


Fig.  7. — Right  paramedian  fracture  with  moderate  loss  of  sub- 
stance.    Loss  of  the  teeth  and  alveolar  border  of  the  right  side. 

fiOG 


PATHOLOGICAL  ANATOMY 


GOT 


The  tendency  to  approach  one  another,  which  is 
manifested  by  the  fractured  portions  in  injuries  of  this 
type,  is  so  strong  that  unless  the  amount  of  substance 
lost  is  positively  prohibitive,  union  is  always  effected. 
Cases  have  come  under  notice  in  which  there  was  union, 
though  with  inevitable  malposition,  between  two 
fragments,  each  of  which  contained  only  molars. 

In  paramedian  fracture  the  tendency  of  the  frag- 


FiG.  8. — Anterior  median  fracture  with  loss  of  two  iijcisors. 
The  dental  adjustment  is  only  slightly  disturbed.  The  median 
lines  coincide;  slight  retraction  of  the  inferior  dental  arch;  slight 
displacement  of  the  molars  inwards.  (The  lower  teeth  are  indi- 
cated by  means  of  dotted  liwes.) 

ments  to  unite  without  superposition  is  very  marked. 
This  tendency  is  common  to  all  varieties  of  the  anterior 
group,  and  constitutes  the  basis  of  classification. 
Where  there  is  no  loss  of  substance,  deformity  is  shght, 
as  in  true  median  fracture. 

Where  there  is  sUght  loss  of  substance,  the  union  of 
the  two  bony  fragments  takes  place  in  the  same 
manner.  The  disturbance  of  balance  betw^een  the 
bony  fragments  and  the  forces  which  act  upon  them  is 


008      FRACTURE   OF   THE   LOWER  JAW 

insuflficient  to  produce  overlapping.  The  surfaces 
come  together  in  close  contact,  thus  compensating  for 
the  absence  of  the  intermediate  bony  structure.  But 
the  effects  on  the  occlusion  are  naturally  more  im- 
portant. The  shorter  fragment  has  no  anterior  teeth, 
but  occludes  satisfactorily  with  the  upper  teeth  ;  the 
larger  fragment  is  considerably  displaced,  as  shown 
in  fig.  9,  the  left  fragment  deviating  to  the  right  to 
the  extent  of  at  least  the  width  of  an  incisor  tooth. 


Fig.  9. — Paramedian  anterior  fracture.  There  is  union  without 
superposition  similar  to  that  in  fig.  8.  The  left  fragment  being 
the  longer,  the  median  line  is  deflected  towards  the  right  fragment. 
(The  lower  teeth  are  indicated  by  means  of  dotted  lines.) 


The  derangement  of  dental  articulation,  though  some- 
what more  marked  than  in  median  fracture,  is  still 
compatible  with  efficient  mastication. 

Where  the  loss  of  substance  exceeds  two  centimetres, 
the  deformity  becomes  much  more  marked.  This  is 
due  to  displacement  of  the  larger  fragment,  the  position 
of  the  smaller  fragment  remaining  practically  normal. 
The  teeth  are  more  numerous  in  the  larger  fragment 
and  their  articulation   is  very  faulty,   sometimes   as 


PATHOLOGICAL  ANATOMY  609 

faulty  as  in  lateral  fracture.  The  tendency  to  unite 
is  appreciably  less  than  in  true  median  fracture,  and 
pseudo-art lirosis  is  a  fairly  frequent  occurrence. 

[h]  Posterior  or  lateral  fracture. — ^The    site   of   frac- 
ture varies  from  the  canine  to  the  last  molar. 
.  Even  wliere  there  is  no  loss  of  substance,  the  dis- 


FiC  10. — Left  lateral  fracture  with  considerable  los;^  of  substance. 
Contact  is  established  by  a  bony  bridge  whicli  proceeds  from  the 
posterior  fragment  and  meets  the  anterior  fragment. 

placement  of  fragments  in  these  cases  is  frequently 
so  great  that  the  last  tooth  of  the  larger  fragment  is 
behind  the  first  tooth  of  the  smaller.  As  a  general 
rule,  however,  deformity  is  the  result  of  an  appreciable 
loss  of  substance. 

Take  the  case  of  a  mandible  fractured  on  the  right 


610       FRACTURE  OF  THE  LOWER  JAW 

side  with  loss  of  substance  corresponding  to  one  tooth, 
the  second  premolar,  for  example.  The  displacement 
of  the  fragments  is  quite  typical,  so  much  so  that  it 
lends  a  characteristic  appearance  (to  be  described  later) 
to  the  face. 

It  is  usually  the  larger  of  the  two  fragments,  the 


Fio.  11. —  Right  lateral  fracture.  Loss  of  substance  correspond- 
ing to  two  molars.  Union  brought  about  by  means  of  an  apparatus 
after  forward  movement  of  the  posterior  fragment. 

one  bearing  the  median  teeth,  which  undergoes  the 
most  marked  displacement  (fig.  12).  It  performs  a 
sort  of  pivoting  movement  around  a  fixed  point  whicli 
corresponds  approximately,  though  perhaps  not 
actually,  to  the  temporo-mandibular  joint  of  the  same 
side.  The  immediate  effect  of  this  movement  is  to 
push  the  middle  teeth  of  the  mandible  backwards  in 


PATHOLOGICAL    ANATOMY  Gil 

such  a  way  that,  when  the  jaws  are  closed,  instead  of 
touching  the  posterior  surface  of  the  maxillary  in- 
cisors, there  is  a  space  between  the  two  rows  which  is 
sometimes  considerable,  and  may  even  amount  to  as 
much  as  a  centimetre. 

But  this  is  not  the  only  result  of  the  pivoting  move- 
ment. The  middle  incisors  are  thrown  towards  the 
fractured  side,  and  although  this  result  does  not  strike 


Fig,  12. — Lateral  fractvire.  Union  with  superposition;  re- 
traction of  the  median  line  with  deviation  towards  the  fractured 
side. 

one  on  casual  observation  it  is  none  the  less  evident 
if  careful  examination  is  made.  If  the  jaws  are  closed 
and  the  lips  are  raised,  it  will  be  seen  that  the  median 
line,  as  marked  by  the  interspaces  between  the  central 
incisors,  is  not  continuous  in  the  two  jaws.  In  the 
mandible  it  leans  towards  the  fractured  side  (fig.  12). 
The  deviation  frequently  amounts  to  the  space  of  one 
tooth,  the  interstice  between  the  inferior  median 
incisors  corresponding  to  that  between  the  superior 
central  and  lateral  incisors  of  the  wounded  side.     The 


612     FRACTURE   OF   THE   LOWER  JAW 

error  may  be  even  greater  still,  and  may  amount  to 
the  space  occupied  by  two  incisors. 

Recission  of  the  middle  teeth  and  deviation  of  the 
median  line  in  the  direction  of  the  fractured  side  are 
the  two  most  fundamental  effects  of  the  displacement 
of  the  fractured  portions.  The  relationship  between 
the  bony  fragments  is,  however,  complex,  and  these 
are  not  the  only  results  of  displacement. 

The  pivoting  movement,  then,  tends  to  bring  the 
two  fractured  surfaces  together,  and  in  some  measure 
to  compensate  for  the  bony  substance  lost.  In  a  few 
instances  perfect  union  is  the  result,  the  fractured 
surface  of  the  larger  fragment  uniting  evenly  with  that 
of  the  smaller,  as  it  is  sometimes  seen  in  paramedian 
fracture.  Perfect  union  does  not  exclude  the  two 
deformities  described  above  with  their  attendant 
facial  asymmetry,  but  it  does  exclude  pseudo-arthrosis. 
Dental  adjustment  is  imperfect,  but  mastication  is 
quite  possible,  and  the  functional  condition  must  be 
regarded  as  tolerable. 

Such  cases  as  these  are,  however,  exceptional.  As 
a  general  rule,  lateral  fracture  with  loss  of  substance  is 
accompanied  by  marked  superposition,  similar  to  that 
seen  in  fractures  of  the  leg  and  thigh.  The  super- 
position is  from  front  to  back  ;  the  segments  of  the 
dental  arch  remain  approximately  upon  the  same 
plane  ;  and  the  end  of  the  larger  fragment  is  usually 
inside  that  of  the  smaller  one  (fig.  12). 

What  are  the  causes  which  tend  to  produce  so  con- 
stant an  arrangement  ? 


PATHOLOGICAL  ANATOMY  <n3 

The  immediate  cause  would  seem  to  be  the  pivoting 
of  the  larger  fragment  upon  its  condyle.  The  fractured 
surface  thus  describes  an  arc  which  takes  it  within, 
or  sometimes  mthout,  the  fractured  surface  of  the 
smaller  fragment.  The  question  arises,  why  should 
it  be  the  larger  fragment  and  not  the  smaller  one  which 
performs  pivoting  movements,  or  at  least  performs 
them    to    a    preponderating    extent  ?     The    ultimate 


Fig.  13. — Lateral  fracture.  The  posterior  fragment  is  directed 
obliquelj'-  forwards,  the  obliquity  being  limited  by  the  teeth  which 
it  contains. 

cause  of  the  movement  seems  to  us  to  He  in  the  action 
of  the  muscles  attached  to  the  mental  spines  and  the 
mylo-hyoid  ridge.  It  is  obvious  that  such  action  must 
exercise  a  preponderating  influence  upon  the  larger 
fragment. 

Viewed  in  this  light,  it  is  easy  to  understand  why  the 
fractured  extremity  of  the  larger  fragment  is  some- 
times within  and  sometimes  mthout  that  of  the  shorter 
fragment. 


6U     FRACTURE  OF   THE  LOWER  JAW 

This,  however,  is  not  all.  Superposition,  whether 
slight  or  marked,  is  accompanied  by  lateral  projection 
of  the  shorter  fragment.  The  latter  contains,  or 
should  contain,  the  inferior  molars  which  become 
projected  outwards.  Where  the  lateral  deviation  is 
slight,  the  internal  or  lingual  cusps  of  the  inferior 
molars  engaga  the  intercuspidal  hollows  of  the  superior 
molars.     Where    the    displacement    is   very   marked, 


Ftg.  14. — Lateral  fracture.  The  posterior  fragment  is  without 
teeth;    its  obliquity  is  more  marked  than  that  in  fig.    13. 

though  this  is  rare,  the  inferior  molars  may  pass  quite 
outside  the  superior  molars  and  fail  to  articulate  with 
them  at  all. 

The  displacement  of  the  larger  fragment  involves 
yet  another  issue  which,  though  more  difficult  of  ob- 
servation, is  none  the  less  characteristic  of  lateral 
fractures,  especially  of  those  accompanied  by  important 
loss  of  substance  :  it  determines  the  position  of  the 
smaller  fragment. 

As  we  have  just  seen,  the  smaller  fragment  is  usually 


PATHOLOGICAL  ANATOMY 


G15 


driven  outwards  by  the  extremity  of  the  larger  frag- 
ment. It  is  also  projected  forwards  in  such  a  way 
that  the  posterior  margin  of  the  ramus,  which  with 
the  subject  in  the  upright  position  should  be  nearly 
vertical,  becomes  gradually  more  oblique,  as  shown  in 
figs.  13,  14,  15. 

In  the  case  of  a  fracture  such  as  that  described,  one, 
namely,  in  which  the  second  premolar  is  absent,  the 


Fig,   15, — Lateral  fracture.     The  line  of  fracture  passes  behind 
the  molars ;    very  marked  obliquity  of  the  posterior  fragn\ent. 

other  teeth  being  present  in  their  entirety,  the  inclina- 
tion from  the  vertical  is  sUght.  It  could  not  become 
accentuated  without  altering  in  the  vertical  sense  the 
dental  plane  of  each  fragment.  Although  the  modifica- 
tion is  slight,  it  is  generally  sufficient  for  the  forward 
deflection  of  the  lower  border  of  the  jaw  to  be  ap- 
preciable. Where  the  smaller  fragment  is  toothless 
(traumatism,  previous  dental  caries),  other  conditions 
remaining  the  same,  the  degree  of  obliquity  is  greater 


61  f!      FRACTURE  OF  THE  LOWER  JAW 

(fig.  14).  It  is  still  more  accentuated  where  the 
position  of  the  fracture  is  behind  the  last  standing 
molar  (fig.  15).    • 

Where  the  loss  of  substance  exceeds  2  cm.,  pseudo- 
arthrosis seems  to  be  the  rule.     It  is  frequent,  even 


Fig.  1 6. — Left  lateral  fracture  with  large  loss  of  substance.  Con- 
tact is  effected  by  means  of  a  bony  bridge  proceeding  from  the 
posterior  fragment.  Fixation  of  the  fragment  by  means  of  an 
apparatus.  The  illustration  shows  the  bridge  by  which  the  frag- 
ments are  immobilised. 

in  cases  where  the  break  in  the  continuity  of  the  bone 
is  comparatively  small. 

(c)  Fracture  of  the  angle. — ^These  cases  closely  re- 
semble those  in  class  (6),  with  this  distinction,  that  the 
smaller  fragment  is  of  necessity  invariably  toothless. 
Hence,    therapeutically    they    constitute    a    separate 


PATHOLOGICAL  ANATOMY  <)17 

group  ;    anatomically   and   clinically   they   belong   to 
class  (6). 

{(l)  Fracture  oi  the  ramus.— These  fractures  are 
difficult  of  observation  :  first,  because  the  seat  of 
injury  is  concealed  beneath  a  dense  muscular  mass  ; 
second,  because  the  derangement  of  function  to  which 


FiO.  17. — Right  lateral   fracture.     Undeveloped  third    rnolar  in- 
volved in  the  region  of  the  fracture  site. 

they  give  rise  is  slight  or  even  nil.  As  a  matter  of 
fact,  we  failed  to  recognise  this  particular  injury  for 
some  months,  and  it  was  its  apparent  and  incompre- 
hensible rarity  which  led  us  to  investigate  the  matter. 
We  then  discovered  that  it  is  far  more  frequent  than 
we  had  imagined,  its  frequency  being  about  the  same 
as  that  of  the  other  groups. 


G18     FRACTURE   OF   THE  LOWER  JAW 

The  teeth,  valuable  guides  as  they  are  in  other 
classes  of  fracture,  are  useless  or  nearly  so  here.  Hence 
it  is  much  more  difficult  in  cases  of  this  sort  to  de- 
termine the  exact  nature  of  the  injury  and  the  nature 
and  degree  of  displacement.  Skiagrams  are  valuable 
aids,  though  difficult  to  obtain  and  also  to  interpret. 


Fig.   18. — Right  lateral  fracture.     Fixation  by  splint. 

Fracture  without  loss  of  substance  may  occur  in  the 
ramus  as  well  as  in  the  body  of  the  bone.  These  cases 
seem  to  progress  simply  without  comphcations  other 
than  possible  constriction.  The  fragments  appear  to 
be  kept  in  place  by  the  strong  muscular  bands  which 
surround  them,  and  thsjre  is  no  tendency  to  any  marked 
displacement  (fig.  20).     Fig.  2]  shows  a  possible  dis- 


PATHOLOGICAL  ANATOMY  'H.') 

placement  of  which  up  to  now  entire  proot  is  not 
forthcoming.  The  two  fragments  are  superimposed, 
the  inferior  being  apparently  outside  the  superior,  the 
position  resembling  that  seen  in  fractures  of  the  follow- 
ing type. 

Where  there  is  loss  of  substance,  a  position  very 


Fig.  19. — Right  lateral  fracture  with  large  loss  of  substance 
and  numerous  splinters.  In  process  of  union  by  immobilisation 
of  the  fragments  in  occlusion. 

characteristic  of  the  lower  jaw  is  frequently  though 
not  invariably  observed.  The  teeth  of  the  fractured 
side  are  brought  into  contact  with  those  above  them, 
a  condition  which  can  only  result  from  a  union  such  as 
is  shown  in  fig.  21a. 
Do  these  fractures  unite  ?    From  the  difficulty  ex- 


620     FRACTURE   OF   THE   LOWER  JAW 


perienced  in  correcting  malposition 
assume  that  they  do,  but  it  is  not 


Fig.  20. — Fracture  of  the  ramus  without 
displacement  of  fragments  or  loss  of  sul^- 
stance.  (This  fracture  does  not  in  any 
way  modify  the  shape  of  the  mandible  ; 
its  presence  is  not  betrayed  by  any  char- 
acteristic malposition ;  the  subjective 
phenomena  and  skiagrams  are  the  sole 
aids  to  diagnosis.) 


in  old  fractures  we 
certain  that  union 
is  invariable . 
Pseudo  -  arthrosis 
is  difficult  to 
diagnose,  which 
suggests  that  it 
has  little  func- 
tional significance. 
It  is  possible  that 
it  occurs  with  some 
frequency,  but,  as 
far  as  our  experi- 
ence goes,  opera- 
tion is  not  indi- 
cated. 


(e)  Double    and    multiple    fracture. — ^These  fractures 
are  fairly  frequent.     In  double  fracture  there  may  be 


Fig.  21. — Fracture  of  the  ramus  with  superposition  of  the  frag- 
ments. (In  fractures  of  this  type  the  superposition  of  the  frag- 
ments is  accompanied  by  shortemng  of  the  ramus, "which  produces 
an  error  of  occlusion.] 


PATHOLOGICAL  ANATOMY 


621 


loss  of  substance  at  one  or  both  fracture  sites.     A 
median  fracture,  or  one  included  in  the  median  line, 


Fig.  2 1  a. — Fracture  of  the  ramus  with  loss  of  substance  and 
subsidence  of  the  fragments.  (The  loss  of  substance  has  been 
followed  by  the  union  of  the  fractured  surfaces,  the  length  of  ths 
ramus  being  thus  decreased  by  the  leagth  of  the  bony  substance 
missing.  The  shortening  ol  ttie  ramus  is  accompanied  by  inevitable 
elevation  of  the  body  of  the  bone  on  the  injured  side,  which  is 
shown  in  occlusion  by  the  malposition  represented  in  this  figure. 
There  is  contact  between  the  superior  and  inferior  molars  of  the 
fractured  side,  and  an  interval  between  those  of  the  sound  side. 
This  interval  is  greatest  in  the  incisor-oanine  region.)' 


FiG.  22. — Loss   of   substance  at   the  temporo- mandibular  joint 
(This  lesion  is  accompanied  by  shortening  of  the  ramus  and  conse 
quent  elevation  of  the  body  of  the  mandible.     Union  produces  a 
malposition  in  occlusion  identical  with  that  shown  in  fig.  21a.) 


C52       FRACTURE  OF   THE  LOWER  JAW 

has  a  tendency  to  fall  inwards.  The  consequent 
lingual  displacement  gives  rise  to  dyspnoea,  which  has 
frequently  been  a  cause  of  mystification  to  surgeons. 
Trachaeotomy  has  been  performed  with  regrettable 
frequency,  in  cases  where  simple  traction  of  the  dis- 
placed median  fragment  would  have  alleviated,  or 
even  abolished,  the  dyspnoea.  The  median  fragment 
is  occasionally  displaced  downwards: 

Where  the  position  of  the  median  fragment  is 
lateral  there  is  also  a  certain  tendency  to  fall  towards 
the  buccal  cavity.  But  as  often  as  not  it  follows  the 
Une  of  deviation  of  one  of  the  other  fragments,  with 
which  its  relation  is  approximately  normal. 

III.    Large  Loss  of  Bony  Substance.    Shattering 

We  have  up  to  now  dealt  exclusively  with  the 
specific  characteristics  of  mandibular  fracture  in 
which  the  loss  of  substance  does  not  exclude  2  to  3  cm. 
But  there  is  a  large  class  of  case  in  which  the  loss  of 
bony  substance  is  far  more  extensive,  the  mandible 
being  sometimes  completely  shattered.  This  class 
comprises  two  groups  ;  those  in  which  the  injury  is 
in  the  body  of  the  bone,  and  those  in  which  it  is  in 
the  rami. 

In  a  comparatively  large  number  of  cases  the  entire 
dental  arch,  together  with  its  bony  support,  is  missing. 
The  fragments  of  the  mandible  still  show  a  tendency 
to  unite,  but  their  small  dimension  renders  this  barely 
appreciable.     The  lesion  is  almost  invariably  accom- 


Plate   1 


Lateral   fracture   of  the  mandible.     (Skiagrams.     Direct   repro- 
duction.) 


PATHOLOGICAL   ANATOMY  623 

panied  by  considerable  deficiency  of  llie  soft  parts, 
with  more  or  less  complete  suppression  of  the  lower 
lip,  and  permanent  salivary  discharge. 

Other  cases  are  tliose  in  which  the  ramus,  together 
with  the  angle  and  a  more  or  less  important  portion  of 
the  dental  arch,  is  missing.  Here  the  injury  is  less 
serious,  a  certain  number  of  teeth  being  preserved. 
The  conditions  somewhat  resemble  those  seen  in  lateral 
fracture.  In  these  cases  the  remaining  portion  of  the 
mandible  deviates  towards  tlie  site  of  injury.  I'he 
deviation  is  accentuated  by  the  fact  that  a  larger 
proportion  of  the  horizontal  part  or  body  of  the  bone 
is  involved  in  the  fracture. 

IV.    Large  Loss  of  Substance  of  the  Soft  Parts 

Gunshot  injuries  of  the  face  are  usually  accompanied 
by  more  or  less  loss  and  laceration  of  the  integument 
and  soft  parts.  The  study  of  such  conditions  forms 
no  part  of  the  object  of  this  book.  It  should  be  kept 
in  mind,  however,  that  the  degree  of  infirmity  may  be 
sensibly  increased  by  the  association  of  these  lesions 
with  those  of  the  bony  parts. 

V.    Anatomical  Development 

In  common  with  all  fractures,  those  of  the  mandible 
terminate  in  either  union  or  pseudo-arthrosis. 

The  length  of  time  required  for  union  varies  con- 
siderably. As  a  general  rule  it  is  shorter  in  simple  than 
in  compound  fracture.     The  vast  majority  of  man- 


624      FRACTURE  OF   THE  LOWER  JAW 

dibular  fractures,  even  where  due  only  to  contusion, 
are  compound,  and  where  there  is  no  wound  of  the 
integument  there  is  usually  injury  to  the  mucosa. 
Occasionally  true  simple  fracture  of  the  mandible  is 
seen,  no  wound  being  present  in  either  integument  or 
mucosa,     In  cases  of  this  sort  the  bony  displacement 


Fig.  23. — Double  bilateral  fracture  with  median  third  fragment. 

must  be  either  very  slight  or  nil.  It  is  our  experience 
that  even  the  small  wound  in  the  mucosa,  by  which 
fracture  of  the  jaw  without  loss  of  substance  is  almost 
invariably  accompanied,  appreciably  hampers  the 
union  of  the  bony  fragments. 

With  rare  exceptions  all  fractures  without  loss  of 
substance  unite.     Muscular  intervention  seems  to  be 


PATHOLOGICAL  ANATOMY  (525 

a  negligible  factor.  Dental  lesions,  on  the  contrary, 
have  considerable  importance.  Union  is  sometimes 
hindered  by  the  presence  of  a  root,  especially  if  broken 
or  carious,  and  more  than  once  union  has  been  effected 
by  the  simple  expedient  of  extracting  one  or  two 
teeth.     Union  of  a  simple  fracture,  or  of  a  compound 


FiG,  2J. — Right  lateral  double  fracLuro  with  intermedial  frag- 
ment. 

fracture  with,  the  wound  in  the  mouth,  without  loss 
of  substance,  is  usually  effected  in  between  two  and 
three  months .  Pseudo-arthrosis  has  not  been  observed 
in  cases  such  as  these. 

In  the  case  of  comminuted  fractures  with  loss  of 
substance  the  chnical  conditions  are  obviously  very 
different.     A  mucii  more  important  part  is  plaj^ed  here 


626     FRACTURE   OF   THE   LOWER  JAW 

by  accessory  conditions  (teeth  projected  into  the 
fractured  part,  splinters  in  the  sequestration  stage). 
Operation  invariably  reveals  a  kind  of  fibrous  callus 
between  the  fragments,  which  is  probably  due  to 
intervention  of  the  soft  parts,  and  is  a  cause  of  the 
pseudo-arthrosis.  But  it  is  the  shape  of  the  broken 
surfaces  which  seems  to  supply  the  chief  factor  in 
promoting  pseudo-arthrosis.  In  the  cases  which  come 
under  operation,  the  fractured  ends  are  almost  in- 
variably pointed. 

The  progress  of  these  fractures  is  a  subject  we  shall 
return  to  later.  For  the  moment  it  is  sufficient  to 
state  that  union  may  take  place  in  one  of  two  ways. 
In  some  cases  the  fractured  surfaces  come  together, 
with  consequent  effaccment  of  the  fracture  site  and 
formation  of  a  bony  callus.  This  is  undoubtedly  the 
better  process,  and  it  should  be  promoted  wherever 
possible.  In  certain  other  cases  the  loss  of  substance 
seems  to  be  made  good  spontaneously,  doubtless  by 
ossification  of  the  periosteal  laminae  which  have  re- 
mained intact.  But  favourable  results  are  hardly  to 
be  expected  except  where  the  loss  of  substance  is 
shght.  Spontaneous  union  occurs  more  readily  in 
median  than  in  lateral  fractures,  and  this  should  be 
borne  in  mind  where  operation  is  contemplated. 

Where  there  is  loss  of  substance,  union  appears  to 
be  appreciably  slower.  Such  fractures  take  at  least 
three  months  to  unite. 

Pseudo-arthrosis  is  fairly  frequent.  We  must,  how- 
ever, define  exactly  what  is  meant  by  the  term  "  pseudo- 


PATHOLOGICAL  ANATOMY 


(^527 


arthrosis."  Retarded  union  is  not  infrequent,  and  is 
almost  invariably  due  to  faulty  methods  of  treatment. 
By  means  of  a  simple  appliance  we  have  succeeded  in 
effecting  a  union  in  the  case  of  fractures  six  months 
old  or  older.  Pseudo-arthrosis  cannot  be  regarded  as 
a   permanent  condition  until  the  fracture  has  been 


Fig,  2o. — Left  commimiled  fracture.  (The  two  lateral  frag- 
ments involve,  one  tiie  alveolar  border,  the  other  the  lower  border. 
Union  is  accomplished  by  apparatus.) 


under  suitable  treatment  for  a  period  which,  to  include 
exceptional  cases,  we  propose  to  fix  at  six  months.  It 
must  be  considered,  not  in  regard  to  the  age  of  the 
fracture,  but  in  relation  to  the  results  of  a  reasoned 
treatment,  methodically  pursued  over  a  period  of  six 
months. 


6:28      FRACTURE   OF   THE   LOWER  JAW 

The  arrangement  of  the  fragments  has  the  same 
significance  in  pseudo-arthrosis  as  it  has  in  recent 
fracture.  In  neglected  cases  the  displacement  is 
frequently  exaggerated,  but  where  treatment  has  been 
carefully  and  methodically  pursued,  the  broken  ex- 
tremities, though  separated  by  a  varjdng  interval,  -will 
face  one  another.  They  are  quite  solid,  the  bony  canal 
being  filled  with  a  dense,  compact,  and  resistant  tissue. 
The  extremity  of  the  larger  fragment  seems,  as  a  rule, 
to  be  the  more  bulky.  The  fractured  surfaces  are 
irregular,  and  are  usually  more  or  less  pointed  in  shape. 
They  are  always  united  by  a  fibrous  band  possessing 
considerable  resistance,  a  sort  of  fibrous  callus,  to 
which  we  shall  have  occasion  to  refer  later,  when  deal- 
ing with  the  subject  of  surgical  intervention. 


CHAPTER    IV 

SYMPTOMS   AND    DIAGNOSIS 

The  symptom-complex  varies  with  the  period  at  which 
the  case  comes  under  treatment. 

AH  mandibular  fractures  pass  through  certain  definite 
stages  of  development. 

During  the  first  stage,  which  lasts  for  a  few  days 
only,  treatment  must  mainly  centre  around  the  pre- 
servation of  life,  for  it  is  at  this  period  that  serious 
complications  are  likely  to  arise,  such  as  infective 
conditions,  dyspnoea,  etc.  At  the  second  stage  the 
fracture  is  termed  "  recent  "  ;  the  work  of  reconstruc- 
tion is  not  begun  but  the  ground  is  prepared  for  it. 
The  minimal  duration  of  this  stage  is  one  month,  its 
maximum  two.  At  the  third  stage  the  fracture  is 
termed  "  old."  This  is  the  really  active  stage  of  treat- 
ment. Its  duration  may  last  for  six  months  or  even 
for  a  year  after  the  date  of  injury.  The  fourth  stage 
comprises  the  treatment,  if  present,  of  pseudo-arthrosis 
and  malposition. 

Fracture  of  the  mandible  is  frequently  accompanied 
by  considerable  damage  to  the  face.  Large  wounds 
such  as  these  are  naturally  liable  to  every  kind  of 
complication.  Moreover,  cases  of  this  kind  are  fre- 
quently  the   subject   of   iU- judged  intervention,   the 

629 


630      FRACTURE   OF   THE    LOWER  JAW 

results  of  wliicli  are  a  source  of  grave  anxiety  to  the 
surgeons  to  whom  llie  eases  are  ultimately  referred. 
Tt  may  to  a  eeitaiu  extent  prevent  repetition  if  we 
briefly  enumerate  these  erroneous  methods  of  procedure. 

Every  one  knows,  if  only  as  the  result  of  earlier 
researches  in  connection  with  resection  of  the  mandible, 
that  extensive  loss  of  the  median  portion  of  the  bone, 
or  double  fracture  with  a  median  third  fragment,  is 
accompanied  by  the  falling  of  the  tongue  into  the 
pharynx.  This  is  due  to  the  abolition  of  the  points 
of  attachment  of  the  genio-glossal  muscles.  Yet  in 
cases  such  as  these,  trachaeotomy  is  frequently 
performed  with  the  idea  of  relieving  the  dyspnoea  or 
preventing  asphyxiation.  Such  a  proceeding  cannot 
pass  uncondemned.  The  obvious  method  is  to  pull 
either  the  fragment  of  bone  or  the  tongue  forward  and 
so  clear  the  air-passages.  The  result  may  be  rendered 
permanent  by  means  of  a  thread  fastened  either  in  the 
integument. or  in  the  ear.  It  must  be  borne  in  mind, 
howevei',  that  where  dysi3n(Ba  is  due  to  the  presence  of 
a  foreign  body,  oedema  of  the  glottis,  etc.,  this  method 
is  quite  useless. 

Sebileau  has  protested  very  strongly  against  these 
trachaeotomies,  the  giavity  of  which  he  emphasises. 
He  also  points  out  that  in  some  instances  gastrostomy 
has  been  performed,  This  operation  can  never  be 
indicated  except  where  ail  instruments  for  oesophageal 
catheterism,  such  as  drains  and  oesophageal  sounds,  are 
lacking. 

It  was  a  conniion  practice  at  the  beginning  of  the 


SYMPTOMS  AND  DIAGNOSIS  6;] 

war  to  suture  the  flaps  at  an  early  stage,  with  the 
object  of  obtaining  quicker  and  better  repair  of  the 
wound.  There  has  been  a  growing  tendency  on  tlie 
part  of  suigery  to  discourage  this  practice.  All  sur- 
geons with  a  war  experience  insist  upon  the  absolute 
necessity  of  opening  up  all  the  passages,  or,  at  least, 
of  not  closing  them.  This  principle  seems  particularly 
applicable  to  injuries  of  the  face,  where  the  wounds 
almost  invariably  communicate  with  the  buccal  cavity 
which  is  naturally  septic.  These  wounds  should  on 
no  account  be  sutured  on  the  skin  side.  On  the  other 
hand,  it  seems  very  expedient  that  wounds  of  the 
mucous  surface  should  be  sutured  as  soon  as  possible. 
Their  restoration  is  not  attended  by  troublesome  after- 
effects, it  has  the  advantage  of  eliminating  a  channel 
of  infection,  and  at  the  same  time  facilitates  any 
plastic  operation  which  may  be  in  contemplation.  It 
has  but  one  drawback — it  is  so  rarely  successful. 

Although  infective  complications  are  undoubtedly 
facilitated  by  untimely  intervention,  these  may  also 
make  their  appearance  in  the  case  of  wounds  which 
have  received  appropriate  treatment.  Before  and 
at  the  commencement  of  the  war,  surgeons  insisted 
upon  the  frequency  of  septic  troubles  as  well  as  upon 
their  gravity.  Now,  however,  such  conditions  are 
observed  in  very  few  cases,  and  when  they  do  arise, 
continue  for  only  a  short  period.  The  benignancy  of 
wounds  of  the  face  is  very  generally  recognised  by 
surgeons  attached  to  base  hospitals,  into  whose  hands 
patients  are  passed  within  an  average  period  of  four- 


032     FRACTURE  OF  THE  LOWER  JAW 

teen  days  from  the  date  of  injury.  In  our  own  service, 
the  number  of  patients  frequently  exceeds  150,  yet 
in  eighteen  months  only  one  has  died.  In  this  instance 
death  was  due  to  general  exhaustion  consequent  upon 
the  rigours  of  the  campaign  rather  than  to  a  true 
septicaemia.  Many  of  our  colleagues,  with  a  number 
of  patients  in  excess  of  our  own,  have  been  stiU  more 
fortunate  and  have  not  reported  a  single  death.  It 
has  been  observed  from  the  beginning  of  the  campaign 
that  gas  gangrene,  which  has  had  such  terrible  and 
far-reaching  results  in  fractures  of  the  limbs,  does  not 
occur  in  connection  with  wounds  of  the  face. 

Apart  from  general  infective  complications,  locai 
infections  of  the  respiratory  passages  are  also  observed. 
If  we  are  to  believe  the  older  text-books,  these  were 
formerly  alarming  in  character  and  of  considerable 
frequency.  These  local  troubles  may  be  occasionally 
observed  at  front-line  stations  ;  they  are  quite  ex- 
ceptional at  the  base. 

The  same  observations  apply  in  the  case  of  secondary 
haemorrhage,  which  occurs  in  connection  with  lesions  of 
the  face  as  of  other  parts,  and  which  is  undoubtedly  of 
septic  origin.  It  is  liable  to  occur  during  the  first 
few  days.  The  suddenness  of  its  onset,  together  with 
the  impossibility  in  most  cases  of  foreseeing  it,  constitute 
a  grave  source  of  danger. 

All  these  complications  are  of  septic  origin.  They 
may  occur  in  connection  with  all  traumatic  wounds  of 
the  face,  but  their  frequency  is  slightly  greater  in 
mandibular  fracture. 


SYMPTOMS   AND  DIAGNOSIS  033 

I,     Recent  Fracture 

After  the  first  period  is  over  and  septic  cou) plica- 
tions are  no  longer  to  be  feared,  the  symptoms  of  frac- 
ture should  be  carefully  investigated. 

Abnormal  Mobility. — Of  the  two  symptoms  which 
are  pathognomonic  to  fracture,  that  of  abnormal 
mobility  alone  has  a  diagnostic  significance  in  fracture 
of  the  mandible.  Crepitation  is  invariably  absent  in 
fracture  with  loss  of  substance;  i\\  simple  fracture  it 
is  difficult  to  obtain.  Where  obtainable  its  production 
causes  great  pain  to  the  patient,  and  is  liable  to  lead 
to  further  lesion  of  the  soft  parts,  especially  tVie  mucosa. 
In  fractures  of  the  body  of  the  bone,  abnormal  mobility 
is  sufficiently  characteristic  to  constitute  a  diagnostic 
sign.     This  is  not  the  case  in  fracture  of  the  ramus. 

The  method  of  determining  abnormal  mobility  varies 
with  the  position  of  the  fracture,  whether  anterior  or 
lateral.  Figs.  26  and  27  show  the  methods  of  obtain- 
ing the  sign. 

In  median  and  paramedian  fracture  each  portion 
of  the  mandible  should  be  firmly  held  between  the 
index  finger  and  the  thumb  with  the  index  finger 
uppermost,  and  the  fragments  should  be  moved  one 
against  the  other.  In  posterior  fracture,  let  us  say  of 
the  right  side,  the  left  thumb  is  introduced  into  the 
mouth  and  pressure  is  exercised  upon  the  teeth  behind 
the  fracture  site,  Avhile  the  angle  of  the  jaw  is  firr^ly 
grasped  by  the  other  fingers  of  the -same  hand.  The 
right  hand  supports  the    other    side  of   the  jaw  and 


634      FRACTURE   OF   THE  LOWER  JAW 

both  hands  endeavour  to  elicit  movement  at  the  site 
of  fracture.  Where  the  site  of  fracture  is  behind  the 
last  molar,  the  thumb  is  planted  firmly  upon  the 
anterior  border  of  the  ramus. 


Fig.  2G, — Showing'  method  of  examination  for  mobiUty  in 
anterior  fracture  (median  or  paramedian).  The  two  fragments 
are  grasped  by  the  thumb  and  index  finger  of  the  two  hands  and 
an  attempt  is  made  to  move  them  one  against  the  other. 


As  in  the  case  of  all  fractures,  slight  mobility  is  not 
always  easy  of  verification.  When  the  teeth  are  all 
present  the  slightest  movement  between  neighbouring 
teeth  is  apparent  to  the  eye.  But  such  a  state  of 
things  is  exceptional.     The  absence  of  several  teeth 


SYMPTOMS  AND  DIAGNOSIS 


035 


is  the  rule,  and  the  sign  is  usually  only  perceptible  to  the 
touch.  Opinions  are  not  always  in  accord,  especially 
as  to  whether  or  not  the  fractured  portions  have 
united.     But  these  cases  are  exceptional,  and,  especi- 


FiG.  27. — Showing  method  of  examination  for  mobihty  in 
lateral  fracture.  The  thumb  of  one  hand  is  introduced  into  the 
mouth  and  is  firmly  planted  upon  the  posterior  fragment,  which 
is  supported  by  the  fingers  of  the  same  hand.  The  anterior  frag- 
ment is  held  in  the  other  hand.  ""An  attempt  is  made  to  elicit  move- 
ment at  the  fracture  site. 


ally  where  there  is  loss  of  substance,  abnormal  mobility 

is  a  diagnostic  sign  which  is  as  a  rule  easy  of  verification. 

In  fracture  of  the  ramus,  however,  this  sign  is  usually 

absent  and  diagnosis  is  consequently  very  difficult. 


G36      FRACTURE  OF   THE   LOWER  JAW 

Skiagrams  when  clear  constitute  the  sole  method  of 
diagnosis. 

Malocclusion. — Fracture  with  loss  of  substance  is 
invariably  accompanied  by  a  certain  degree  of  mal- 
occlusion. The  malocclusions  accompanying  difTerent 
types  of  fracture  have  been  described  in  a  previous 
chapter.  The  principal  characteristics  may  be  briefly 
summarised  as  follows  : 

1.  In  anterior  fracture  the  fragments  are  in  contact 
without  tending  to  overlap.  The  dental  arch  is  there- 
fore narrowed,  and  tends  to  assume  a  pointed  shape 
(reptilian  jaw).  The  apex  of  the  arch  is  consequently 
distal  to  the  upper  incisor  teeth.  The  lower  side  teeth 
become  internal  to  the  upper  side  teeth.  The  de- 
formity is  more  accentuated  in  the  front  than  in  the 
back  of  the  mouth.  In  paramedian  fracture,  thewhole 
of  the  teeth  of  the  sound  side  tend  to  be  displaced 
towards  the  fracture  site,  the  displacement  correspond- 
ing to  one  or  two,  or  even  more,  teeth. 

2.  In  lateral  fracture  the  deformity  is  more  complex. 
The  long  fragment  inclines  towards  the  fractured  side, 
the  median  line  being  diverted  in  the  same  direction. 
Its  extremity  is  usually  inside  the  shorter  fragment, 
A^hifch  moves  forward  to  compensate  for  the  loss  of 
substance.  Owing  to  the  fact  that  the  shorter  frag- 
ment IS  practically  fixed  at  the  level  of  the  temporo- 
mandibular joint,  this  movement  can  only  be  accom- 
plished by  elevation  of  the  fractured  extremity  (figs. 
13,  14,  15).  This  elevation  is  more  or  less  pronounced 
according  to  the  number  and  position  of  the  remaining 


I'l-ATB     II 


Lateral  fracture  of  the  mandible.  Photographs  show  the  full- 
face  and  the  profile  of  the  fractured  side.  Deviation  of  the  chin 
towards  the  fractured  side.  The  face  on  the  same  side  appears 
shortened.  The  skin  is  elevated  by  overriding  of  the  fragments. 
There  is  frequencly  a  cicatrix.  The  sound  side  appears  prolonged 
and  flattened,  without  a  cicatrix. 


I 


SYMPTOMS  AND  DIAGNOSIS  B37 

teeth  of  the  fractured  side.  It  is  particularly  marked 
in  certain  fractures  of  the  angle. 

3.  The  deformity  accompanying  fracture  of  the 
ramus  is  characterised  by  malocclusion  of  a  character- 
istic type,  the  teeth  of  the  fractured  side  meeting 
while  there  is  still  an  interval  between  those  of  the 
sound  side  (figs.  20,  21,  22). 

Ill  fracture  without  loss  of  substance  the  displace- 
ment of  fragments  is  very  slight  or  nil.  Occasionally 
it  appears  more  marked,  but  this  is  only  apparent,  and 
is  due  to  the  malposition  of  teeth  partially  loosened 
from  their  sockets,  or  to  alveolar  fracture.  Where 
the  displacement  is  real,  */he  teeth  of  one  fragment 
will  be  displaced  in  either  the  vertical  or  horizontal 
plane.  In  either  case  correction  of  the  deformity  is 
usually  simple. 

The  symptoms  of  double  fracture  are  easily  recog- 
nised by  the  methods  described.  There  is  character- 
istic displacement  of  the  mobile  fragment.  It  tends  to 
drop  downwards  and  to  remain  loose,  with  the  result 
that,  in  occlusion,  when  the  posterior  teeth  are  in 
contact  the  anterior  teeth  are  separated  by  a  gap  of 
two  to  three  millimetres.  Fractures  of  this  kind  may 
easily  unite  in  malposition. 

Facial  Asymmetry. — In  the  Presse  medicale  (25.  X. 
1915)  we  published  an  account  of  the  facial  asymmetry 
characteristic  of  different  fractures  of  the  mandible. 
It  is  most  pronounced  in  lateral  fracture.  The  features 
of  asymmetry  are  usually  sufficiently  marked  to 
reveal  at   a  glance  the  nature  of  the  lesion.     This 


()38     FRACTURE  OF   THE  LOWER  JAW 

applies  also  to  cases  in  which  union  has  long  been 
effected.  The  characteristic  signs  of  asymmetry  are 
as  follows  : 

1.  The  median  line,  with  the  chin,  is  deflected 
towards  the  fractured  side.  The  deviation  is  very 
apparent  and  has  the  effect  of  emphasising  the  sound 


Fio.  28. —  Zones  of  anaesthesia  in  fracture  of,  the  body  of  the 
mandible. 

side,   which,   in  comparison  with  the  other,  appears 
prolonged  and  more  prominent. 

2.  The  fractured  side  presents  a  degree  of  tume- 
faction which  corresponds  to  the  fracture  site  and  is 
due  to  the  presence  of  the  callus,  displacement  of 
fragments,  etc. 

3.  The  prominence  of  the  angle  of  the  jaw  of  the 


SYMPTOMS   AND  DIAGNOSIS  039 

fractured  side  is  abolished.  Displacement  of  the 
smaller  fragment  causes  the  posterior  border  of  the 
bone  to  slope  forward,  with  the  result  that  in  profile 
it  appears  flattened  and  retreating. 

4.  The  skin  in  the  neighbourhood  of  the  fracture  is 
usually  disfigured  by  a  cicatrix  of  varying  importance. 

Cutaneous  Anaesthesia. — We  have  shown,  with 
Gaiithier  and  Lheureux,  that  anaesthesia  of  the  chin  is 
a  certain  sign  of  fracture  of  the  mandible.  It  is  par- 
ticularly useful  in  old  cases  where  union  has  taken 
place  some  time  previously  and  where  retrospective 
diagnosis  is  difficult. 

This  anaesthesia  is  of  course  due  to  section  of  the 
inferior  dental  nerve,  either  in  the  canal  or  immediately 
in  its  vicinity.  It  is  not  observed  in  median  and  para- 
median fracture,  nor  in  fracture  of  the  ramus  when  this 
is  situated  above  the  opening  of  the  inferior  dental 
canal.  It  seems,  however,  to  be  constant  in  lateral 
fracture.  The  zone  of  anaesthesia  occupies  a  practically 
circular  area  upon  the  chin  of  a  diameter  of  three  to 
four  centimetres,  and  this  is  prolonged  on  to  the  cor- 
responding region  of  the  lower  lip.  It  frequently 
happens,  though  this  is  not  a  constant  sign,  that  there 
is  anaesthesia  of  the  mucosa  of  the  cheek  and  of  the 
external  gum  as  far  as  the  fracture  site.  Insensibility 
of  the  inner  gum  is  occasionally  observed,  but  we 
have  found  it  a  very  inconstant  sign. 

1  It  should  be  borne  in  mind  that  the  continuity  of  the  sensory 
nerves  is  sometimes  interrupted  b}-  cicatrices.  Hence  irretfular 
areas  of  anaesthesia  arise,  and  these  are  hablc  to  be  confused  with 
tlie  resuhs  produced  by  section  of  the  mental  nerve. 


640      FRACTURE  OF  THE  LOWER  JAW 

There  is  of  course  anaesthesia  of  the  teeth  up  to  the 
median  line.  This  is  readily  tested  by  means  of  a 
thermo-  or  galvano-cautery.  Sharp  pain  results  from 
its  application  to  the  teeth  of  the  fractured  side,  while 
those  of  the  sound  side  do  not  react. 

Examination  for  abnormal  mobility  is  usually 
accompanied  by  little  pain  in  mandibular  fracture. 
The  explanation  lies  in  the  lack  of  sensibility  of  the 
anterior  fragment. 

II.     Old  Fracture 

Except  in  regard  to  modifications  brought  about 
by  union  or  by  methods  of  treatment,  the  signs  of 
old  fracture  are  similar  to  those  of  recent  fracture. 

Where  there  is  pseudo-arthrosis,  abnormal  mobility 
is  usually  very  marked  and  may  be  readily  obtained 
by  the  methods  described. 

Malocclusion  and  facial  asymmetry  are  more  or 
less  pronounced  according  to  the  results  of  treatment. 
In  the  case  of  old  fractures  which  have  not  come 
under  treatment  (such  are  still  occasionally  met  with), 
the  deformity,  independently  of  union,  resembles 
that  of  recent  fracture.  In  such  cases  methodical 
treatment,  though  it  may  not  effect  a  union,  almost 
invariably  succeeds  in  getting  the  larger  fragment  into 
good  position.  Occlusion  of  the  major  portion'  of  the 
dental  arch  is  thus  established,  and  the  chin  i«  brought 
into  the  median  line.  The  asymmetry  affects  only 
the  smaller  fragment,  which  retains  its  oblique  and 
receding  attitude,  the  teeth  where  present  interdigita- 


SYMPTOMS  AND  DIAGNOSIS  G41 

ting  more  or  less  imperfectly  with  those  of  the  upper 
jaw. 

Anaesthesia  in  the  vicinity  of  the  mental  nerve  seems 
to  be  constant.  It  is  present  in  the  oldest  fractures 
independently  of  union.  And  it  is  unaffected  by  the 
results  of  osteo-synthetic  intervention.  For  these 
reasons  it  constitutes  a  reliable  retrospective  sign  in 
mandibular  fracture. 

Old  fractures  are  frequently  complicated  by  sinuses. 
These  as  a  rule  are  not  deep,  and  lead  either  to  a  centre 
of  necrosis,  sequestrated  or  not,  or  to  an  osteitic  cavity. 
All  surgeons  know  how  tenacious  and  persistent  these 
sinuses  are  when  they  occur  in  connection  with 
fracture  of  a  long  bone,  especially  the  femur.  To 
close  them  requires  the  most  minute  and  prolonged 
care.  Such  is  fortunately  not  the  case  in  sinuses 
about  the  mandible.  If  the  passage  is  weU  opened 
up  and  curetted,  healing  is  certain  to  follow.  The 
curette  frequently  brings  away  fungoid  growths, 
small  sequestra,  the  root  of  a  tooth,  or  even  a  tooth 
itself  displaced  at  the  time  of  injury  by  the  projectile. 

Facial  paralysis  is  frequent  in  both  old  and  recent 
fracture.  We  have  made  no  searching  investigation, 
but  it  is  safe  to  say  that  spontaneous  recovery  is 
frequent. 

III.    Fracture    of   the   Angle 

This  variety  is  closely  allied  to  lateral  fracture  and 
presents  similar  appearances :  abnormal  mobility, 
facial  asymmetry,  malocclusion.     Separate  classifica- 


642      FRACTURE   OF   THE   LOWER  JAW 

tion  would  not  be  necessary  were  it  not  that  the 
condition  presents  a  characteristic  therapeutic  diffi- 
culty. Owing  to  the  fact  that  the  site  of  fracture 
passes  behind  the  last  molar,  the  posterior  fragment 
is  invariably  without  teeth.  Consequently  it  is  not 
possible  to  apply  prothetic  mechanisms  by  the  usual 
methods.  Hence  the  classification  is  therapeutic 
rather  than  clinical.  Surgical  intervention  has  never 
in  our  experience  been  indicated.  Unless  there  is 
large  loss  of  bony  substance,  these  fractures  unite 
readily  under  mechanical  treatment. 

IV,    Fracture    of   the    Ramus 

The  frequency  is  about  the  same  as  in  the  other 
classes  of  fracture,  but  the  principal  signs  are  absent 
and  diagnosis  is  consequently  more  difficult.  On  the 
other  hand  the  deformity,  once  its  nature  is  recog- 
nised, is  very  cl^aracteristic.  On  closure  of  the  jaws 
the  teeth  of  the  fractured  side  come  into  contact  with 
those  above  them,  while  the  teeth  of  the  sound  side 
are  still  separated  by  an  appreciable  inteival  (see 
p.  iSllet  seq.).  The  condition  can  only  be  accurately 
diagnosed  by  means  of  skiagrams. 

V.     The   use    of   Radiographs    in    MA^DIBULAR 

Fracture 

As  in  the  case  of  all  the  curved  bones,  radiography 
presents  special  difficulties.  The  parts  most  difficult 
of  observation  are  the  anterior  or  mental  portions,  and 
the  highest  part  of  the  ramus,  namely,  the  condyle. 


SYMPTOMS  AND  DIAGNOSIS 


G43 


It  will  be  seen,  however,  that  in  the  majority  of  our 
skiagrams  the  ramus,  the  condyle,  and  even  the 
coronoid  process  are  all  well  shown. 

Skiagrams  of  the  lateral  branches  and  of  the  lower 
portion  of  the  ver- 
tical branches  give 
valuable  results. 
It  is  of  course 
necessary  to  take 
a  separate  picture 
of  each  side.  The 
secret  of  obtain- 
ing successful  pic- 
tures lies  in  taking 
the  mandible  at  a 
very  oblique  angle, 
in  such  a  way  that 
the  part  of  the 
bone  which  is  not 
in  contact  with 
the  plate  is  pushed 
as  far  back  as 
possible  and  does 


Fig,  29. — Diagram  showing  the  method 
of  interpretation  of  skiagrams  of  the 
mandible.  The  skiagram  is  intended  to 
show  the  left  side  of  the  bone,  (1  and 
2,  superior  and  inferior  rows  of  teeth  of 
the  left  side ;  3  and  4,  rows  of  teeth  of 
the  right  side-^— by  the  obliquity  of  the 
rays  these  latter  are  removed  as  far  as 
possible  from  the  image  of  the  left  side ; 
5,  left  coronoid  process;  6,  left  condyle. 
The  latter  is  marked  with  a  cross,  which 
is  reproduced, ,  and  serves  as  a  guide  in 
skiagrams  of  mandibulai*  fracture.) 


not  obscure  the 
image  which  it  is  desired  to  obtain.  This  result  is 
not  always  obtainable,  the  two  images  sometimes 
appearing  in  a  certain  degree  of  juxtaposition.  Such 
proofs  are  very  difficult  to  interpret.  For  this  reason 
a  few  hints  on  the  management  of  skiagrams  in 
mandibular  fracture  will  not  be  out  of  place. 


644      FRACTURE  OF   THE  LOWER  JAW 

Fig.  29  is  a  reproduction  of  a  drawing  from  a  skia- 
gram obtained  under  the  most  favourable  conditions. 
It  shows  the  outline  of  the  left  side  of  the  bone.  The 
condyle  and  its  neck,  as  well  as  the  coronoid  process, 
are  clearly  seen.     But  results  are  by  no  means  always 


Fig.  30. — Skiagram  obtained  by  application  of  the  full-face  to 
the  plate. 

SO  happy.  Where  there  is  insufficient  obliquity  of 
the  rays  these  parts,  as  well  as  the  ramus,  are  more 
or  less  confused  with  the  image  of  the  ramus  of  the 
opposite  side.  Or,  as  sometimes  happens,  they  are 
obscured  by  the  details  of  the  cervical  vertebrae. 
And  it  must  be  borne  in  mind  that,  even  in  cases 
where   a    sufficiently   clear   image   is   obtained,    the 


SYMPTOMS  AND  DIAGNOSIS  G45 

obliquity   of   the   rays   sensibly   deforms   the   outline 
of  the  upper  portions  of  the  bone. 

The  X-rays  successively  encounter  the  dental 
alignment  of  the  right  side  and  of  the  left,  hence  four 
rows  of  teeth  should  appear  in  the  picture.  The  two 
lower  rows  represent  the  superior  and  inferior  teeth 
of  the  side  nearest  to  the  plate.  This  image  is  the 
clearer  and  it  is  the  one  which  it  is  desired  to  obtaiji. 
Thft  two  upper  rows  represent  the  image,  or  rather 
the  radiographic  shadow,  of  the  upper  and  lower 
teeth  of  the  side  furthest  removed  from  the  plate. 
This  is  the  image  which  it  is  not  desired  to  obtain. 
The  obliquity  of  the  rays  should  correspond  exactly 
to  the  distance  from  the  field  at  which  it  is  desired 
to  place  the  second  image.  The  excellence  of  the 
skiagram  depends  upon  the  lack  of  clearness  of  the 
second  image  and  its  distance  from  the  first.  In  a 
bad  picture,  both  images  are  projected  at  approxi- 
mately the  same  point,  the  outlines  which  should  be 
separate  thus  becoming  confused.  The  difficulties 
of  the  method  should  not  be  allowed  to  be  a  cause 
of  discouragement,  for  in  mandibular,  as  in  other 
fractures,  good  skiagrams  are  valuable  diagnostic  aids 

VI.    Closure  of  the  Jaws 

Closure  of  the  jaws  is  perhaps  the  most  frequent 
complication  of  wounds  of  the  face,  but  as  far  as  our 
experience  goes  it  is  infrequent  in  mandibular  fracture 
and  particularly  so  where  the  fracture  is  complete. 


646      FRACTURE   OF   THE   LOWER  JAW 

In  another  place  we  have  described  a  hypermyotonic 
form  which  is  very  common.  In  our  experience  it 
includes  four-fifths  of  cases.  Its  characteristics  are  : 
The  comparative  insignificance  of  the  wound,  which 
is  sometimes  unaccompanied  by  even  incomplete 
fracture ;     the   fact   that,    by   the   method   described, 


Fig.  31. — Fracture  of  the  angle,  right  side.  Marked  obliquity 
of  the  posterior  fragment. 

the  mouth  may  be  opened  at  one  sitting ;  and  the 
precipitate  nature  of  the  condition,  the  mouth  shutting 
immediately  upon  injury.  As  a  matter  of  fact  this 
form   of    closure,    though    frequently   accompanying 

I  La  constriction  des  machoires  par  blessures  de  guerre,  Academie 
de  Medecine,  February,  1916.  Presse  medicale,  August  24th,  1916. 
Interallied  Dental  Congress,  1916.      Presae  medicale,  February,  1917. 


SYMPTOMS  AND  DIAGNOSIS  (JIT 

mandibular  fracture,  does  not  seem  to  be  caused  by  it. 
The  same  applies  to  the  cicatricial  form,  which  is  the 
outcome  of  more  or  less  important  destruction  of  the 
soft  parts. 

The  presence  of  fibrous  bands  in  the  subcutaneous 
and  submucous  structures  is  another  cause  of  closure 


Fig.  32. — Fracture  of  the  ramus,  right  side. 

of  the  jaws.  In  some  instances  these  are  due  to  pro- 
longed superficial  cicatrices  with  sclerosis  affecting 
either  the  temporal  muscle  or  the  masseter.  More 
frequently  a  more  or  less  resistant  area,  which  is 
sometimes  very  rigid,  is  observed  beneath  the  buccal 
mucosa.  This  it  is  which  prevents  the  -  depression 
of  the  mandible. 


648      FRACTURE  OF   THE  LOWER  JAW 

But  all  these  forms  of  closure  are  present  in  mandi- 
bular fracture  solely  as  complications  of  accessory- 
lesions  of  the  soft  parts.  In  closure  arising  from 
ankylosis  of  the  temporo-mandibular  joint,  however, 
the  case  is  otherwise.  It  is  readily  conceivable  that 
injury  to  this  joint  and  to  the  bony  masses  in  its 


Fitf.  33.—  Complete  ankylosis  of  the  temporo-mandibular  joint. 
Post-mortem  specimen  from  a  man  who  had  suffered  violent 
traumatism  many  years  previously.  The  dental  arch  of  the  same 
side  was  bent  inwards;  the  other  temporo-mandibuleir  joint, 
immobiUsed  at  the  same  time,  was  quite  normal. 


vicinity  may,  as  in  the  case  of  other  joints,  provoke 
ankylosis  by  union  of  the  articulating  bony  surfaces. 
Such  a  condition  among  patients  of  war  has  never 
been  observed  by  us.  One  case,  however,  came  under 
notice,  that  of  a  civilian.  The  patient  was  a  young 
man  of  twenty  who  was  brought  to  the  Hotel-Dieu 


SYMPTOMS  AND  DIAGNOSIS  649 

at  Marseilles  with  a  gunshot  wound  in  the  dorso- 
lumbar  region.  There  was  injury  to  the  cord  with 
paraplegia.  At  the  time  when  he  came  under  observa- 
tion the  injury  was  several  months  old  and  his  general 
condition  forbade  surgical  intervention.  Now  for 
several  years  this  man  had  suffered  from  absolute 
constriction  of  the  jaws.  The  mandible  was  incapable 
of  performing  the  slightest  movement,  either  active 
or  passive.  Nevertheless  long  habit,  together  with  the 
absence  of  several  teeth,  had  allowed  him  to  assimilate, 
his  food,  and  his  general  development  was  absolutely 
normal.  He  had  even  formed  one  of  a  gang  of  Mar- 
seilles roughs,  and  his  unlucky  star  alone  was  respon- 
sible for  an  "  accident "  which  doubtless  made  of  the 
aggressor  a  victim.  The  photograph  shows  the  con- 
dition of  the  joint  after  death  ;  ankylosis  was  com- 
plete. From  what  we  could  afterwards  learn,  the 
lesion  was  the  result  of  a  fall  from  a  height  in  child- 
hood. It  is  an  interesting  fact  that  the  other  temporo- 
mandibular joint,  in  spite  of  its  long  immobilisation, 
was  entirely  normal. 

We  have  had  no  personal  experience  in  the  treat- 
ment of  this  form  of  closure.  For  information  con- 
cerning the  operative  measures  which  are  indicated 
in  the  condition,  we  cannot  do  better  than  refer  the 
reader  to  the  writings  of  Ombredanne. 

VII.    Clinical  Development 

The  details  of  this  subject  have  been  largely  dealt 
with  in  the  chapter  on  pathological  anatomy.     Clinical 


(;."50      FRACTURE   OF   THE  LOWER  JAW 

progress  in  mandibular  fracture  terminates  normally 
in  union,  with  more  or  less  malposition  according  to 
the  amount  of  substance  lost.  The  question  of  sinuses 
has  already  been  discussed. 

(a)  Pseudo-arthrosis. — As  we    have    already   pointed 
out,  and  shall  again  have  occasion  to  repeat,  pseudo- 


FiG.  34. — Left    lateral    fracture    with    largo    loss    of    substance. 
Permanent  pseudo-arthrosis. 

arthrosis  is  not  established  until  mechanical  treatment 
has  been  pursued  for  some  considerable  time.  A  period 
of  at  least  six  months  should  be  allowed.  Occasion- 
ally, however,  as  in  shattering  'of  the  mandible  with  large 
loss  of  substance,  no  known  therapeutic  measure  is  able 
to  overcome  it  and  it  must  be  regarded  as  inevitable. 
In  the  case  of  the  jaw,  pseudo-arthrosis  does  not 


SYMPTOMS  AND  DIAGNOSIS  051 

possess  the  absolute  functional  significance  only  too 
frequently  attaching  to  it  in  connection  with  fracture 
of  the  long  bones.  Nevertheless  the  degree  of  in- 
capacity which  it  is  able  to  produce  is  frequently  con- 
siderable. In  simple  pseudo-arthrosis,  where  the  loss 
of  substance  is  not  very  extensive,   performance  of 


Fig.  35. — Left  lateral  fracture  with  large  loss  of  substance. 
Mechanical  treatment  resulted  in  slight  pseudo-arthrosis  with  good 
occlusion. 

function  is  still  possible  though  it  is  naturally  very 
imperfect.  Mastication  of  hard  substances  is  impos- 
sible, but  all  soft  foods,  such  as  crumb  of  bread,  tender, 
well-cooked  meat,  etc.,  can  be  consumed.  Where, 
however,  a  large  proportionof  the  dental  arch  is  missing, 
and  even  where  only  half  the  mandible  is  out  of  play, 


652     FRACTURE   OF   THE  LOWER  JAW 

mastication  is  practically  impossible.  Only  food  in 
a  condition  fit  to  swallow  should  be  introduced  into 
the  mouth.  Trituration  is  a  function  of  the  tongue, 
and,  as  may  be  readily  imagined,  its  performance  in 
this  direction  is  very  much  reduced. 

From  the  functional  point  of  view,  then,  there  are 
degrees  of  pseudo-arthrosis.  That  this  is  also  the  case 
in  regard  to  treatment  we  shall  see  later. 

{h)  Types  of  Malocclusion  observed  in  United  Mandi- 
bular Fracture. — The  various  types  of  malooelusion 
which  follow  union  in  mandibular  fracture  are  asso- 
ciated with  deformity  in  varying  degree.  These  defor- 
mities reproduce  the  characteristic  bony  displacements 
which,  not  having  been  reduced  by  clinical  methods, 
have  become  fixed. 

Median  and  paramedian  fracture  are  followed  by 
mandibular  atresia  due  to  linguo-version  of  the  frag- 
ments. Lateral  fracture  and  fracture  of  the  angle 
are  followed  by  lateral  deviation  and  retraction  of  the 
larger  fragment,  with  displacement  above,  in  front  of, 
and  outside  the  posterior  fragment.  Faulty  union  of 
the  ramus  may  be  revealed  by  an  interval  on  closure 
between  the  teeth  of  the  sound  side,  with  slight  re- 
traction. These  are  definite  anatomical  lesions,  and 
correction  of  the  malocclusion  associated  with  them 
is  only  possible  where  the  normal  shape  and  orienta- 
tion of  the  jaw  can  be  restored  by  surgical  or  mechani- 
cal means. 

Where  the  callus,  as  shown  by  skiagrams,  has  not 
undergone  complete  ossification,  mechanical  measures 


SYMPTOMS  AND  DIAGNOSIS  653 

should  yield  the  best  results.  The  mechanisms,  to  be 
described  later,  are  similar  to  those  employed  in 
reducing  old  fractures. 

If  the  callus  has  undergone  ossification,  correction 
of  the  deviation  can  be  obtained  only  by  surgical 
means.  The  most  favourable  operation  is  undoubtedly 
oblique  osteotomy,  so  frequently  employed  in  the 
surgery  of  the  limbs.  We  ourselves  have  never  had 
occasion  to  employ  it,  but  it  ought  to  be  attended  by 
excellent  results  in  cases  such  as  these.  It  has  fre- 
quently been  employed  with  satisfactory  results  by 
Sebileau.  The  oblique  incision  permits  the  separa- 
tion of  the  two  fragments,  the  angular  extremities 
being  kept  together  by  means  of  a  plate.  The 
immobilisation  thus  obtained  is  reinforced  by  a 
mechanism  attached  to  the  teeth,  which  re-establishes 
the  normal  occlusion.  In  addition  to  the  malocclu- 
sions due  to  serious  bony  lesion,  there  is  yet  another 
form  the  pathology  of  which  is  complex  and  its 
symptomatology  entirely  specific. 

This  type  of  malocclusion  is  seen  after  fracture  of  the 
horizontal  portion  of  the  mandible.  It  is  characterised 
by  a  more  or  less  marked  tendency  to  lateral  deviation 
of  the  whole  of  the  mandible  of  the  fractured  side, 
with  the  result  that  the  dental  arches  no  longer  coin- 
cide and  all  functional  activity  is  lost. 

This  position  is  maintained  even  in  repose.  When 
the  jaws  are  closed  the  dental  arches  are  intercrossed, 
their  sole  contact-point  being  in  the  incisor  region. 
The  deviation  becomes  accentuated  when  the  jaw  is 


G54      FRACTURE  OF   THE  LOWER  JAW 

dropped.  The  deflection  of  the  mandible  towards  the 
fractured  side  produces  a  similar  deformity  of  the 
buccal  opening,  lending  to  it  a  very  characteristic 
appearance,  rather  happily  termed  bouche  du  chantre 
de  village  (village   singer's  mouth)  (figs.  36  and   37). 


Fig.   36. — Lateral   deviation  known  as  "  bouche  du  chantre  de 
village"  (village  singer's  mouth). 


In  extreme  cases  it  is  almost  impossible,  even  by 
the  exertion  of  considerable  physical  force,  to  reduce 
temporarily  this  deviation.  In  any  case  such  reduc- 
tion is  accompanied  by  intense  pain  in  the  region  of 
the  temporo-mandibular  joint. 


SYMPTOMS  AND  DIAGNOSIS 


655 


In  most  cases  normal  occlusion  can  be  momentarily 
re-established  by  the  exercise  of  more  or  less  extreme 
pressure  in  the  direction  contrary  to  the  deviation. 
But  as  soon  as  pressure  is  removed,  the  deviation  is 
instantly  reproduced  by  a  lateral  movement  of  the 


Fig.  37. — Lateral  deviation  known  as  "  bouche  du  chantre  de 
village."  (The  lips  are  held  back  to  show  the  position  of  the  dental 
arches.) 

mandible,  which  the  patient  declares  that  he  is  unable 
to  control. 

What  is  the  cause  of  this  malposition  ?  All  the 
patients  in  whom  we  have  observed  it  appear  to  have 
suffered  neglect  of  their  maxillo-facial  injuries.      In 


656      FRACTURE  OF   THE  LOWER  JAW 

some  instances  they  never  came  under  special  treat- 
ment. Their  jaws  united  without  mechanical  aid, 
the  deviation  establishing  itself  by  degrees  without 
attracting  particular  attention.  In  others,  they  had 
received  special  treatment,  immobilisation  mechanisms 
had  been  fitted  to  them  and  they  had  then  been  sent 
to  their  homes  as  convalescents.  It  is  probable  that, 
owing  to  lack  of  proper  supervision,  the  vicious 
attitude  developed  during  this  leave.  In  spite  of  very 
close  observation  we  have  not  observed  the  condition 
to  develop  in  a  patient  while  under  our  care.  This 
seems  to  prove  that,  like  the  constriction  of  the  myo- 
tonic jaw,  la  bouche  du  chantre  de  village  is  a  con- 
dition which  may  be  guarded  against  by  means  of 
suitable  treatment. 

At  first  sight  its  pathogenesis  seems  obscure.  The 
deformity  of  the  mandibular  arch  cannot  be  regarded 
as  an  etiological  factor,  for  we  have  frequently  observed 
that,  in  these  cases,  there  was  little  or  no  deformity  of 
the  mandible  and  that  the  normal  concordance  of  the 
arches  was  intact.  This  was  proved  by  taking  plaster 
models  of  the  two  arches  which,  when  superimposed, 
met  in  perfectly  normal  occlusion. 

Upon  further  investigation  it  became  evident  that 
the  horizontal  portion  of  the  mandible  had  undergone 
a  slight  but  distinct  reduction  in  length.  The  dis- 
tance from  the  angle  to  the  chin  of  the  sound  side  was 
about  one  cm.  longer  than  that  of  the  fractured  side. 
This  reduction  had  no  influence  upon  the  general 
outline  of  the  mandibular  arch.     Such  reduction  is 


SYMPTOMS  AND  DIAGNOSIS  657 

nearly  constant  in  all  united  fractures  without  malocclu- 
sion, and  we  do  not  believe,  therefore,  that  the  slight 
shortening  of  the  horizontal  portion  can  be  regarded 
as  the  ultimate  cause  of  the  condition. 

The  same  holds  good  of  the  articular  modifications. 
In  attempting  the  reduction  of  the  deformity,  a  varying 
degree  of  stiffness  of  the  joint  is  encountered.  This 
symptom  is  of  varying  constancy.  In  our  opinion 
this  is  a  secondary  condition,  consequent  upon  the  dis- 
placement of  the  articular  surfaces  and  of  the  meniscus 
and  their  fixation  in  abnormal  position. 

It  seems  to  us  that  the  malposition  known  as 
bouche  du  chantre  de  village  is  not  due  to  bony  or  articu- 
lar lesion,  but  is  the  outcome  of  functional  derange- 
ment of  the  masticatory  muscles.  As  a  result  of 
the  fracture,  the  patient  adopts  an  attitude  which 
he  at  first  corrects  spontaneously,  and  which  un- 
doubtedly he  could  completely  overcome  were  he  to 
practise  what  neurologists  term  Veffort  inverse,  or 
if  his  will-power  were  reinforced  at  the  psychological 
moment  by  a  suitable  mechanism.  The  vicious  atti- 
tude becomes  still  further  ingrained  by  muscular  pheno- 
mena of  the  dynamic  kind,  very  specific  to  the  con- 
dition and  characterised  by  hypertonicity  and  hyper- 
excitability  of  the  muscles  of  the  fractured  side. 
These  dynamic  phenomena  appear  to  withdraw  the 
affected  muscles  from  the  influence  of  the  will-power. 
A  sort  of  disequilibrium  results,  a  lack  of  co-ordination 
in  the  movements  of  mastication,  the  muscular  synergy 
having  disappeared. 


058      FRACTURE   OF   THE   LOWER  JAW 

It  is  for  this  reason  that  bouche  du  chantre  de 
village  is  included  in  the  syndrome  which  we  have 
termed  myotonic  constriction  of  the  jaws.  This,  in 
its  turn,  is  included  in  a  group  of  myotonias  described 
by  neurologists  (Sicard,  Babinski) — namely,  incurvation 
of  the  trunk  (camptocormia),  main  en  benitier, 
main  en  col  de  cygne,  etc. 

There  is  moreover  another  striking  analogy  between 
myotonic  constriction  and  bouche  du  chantre  de 
village.  The  latter  is  sometimes  seen  where  no  frac- 
ture is  present,  as  the  result  of  slight  lesions  of  the 
cervical  region,  such  as  superficial  wounds  and  muscu- 
lar seton.  We  have  observed  a  similar  etiological 
peculiarity  in  the  case  of  myotonic  constriction. 

Provided  that  a  suitable  treatment  is  instituted  at 
an  early  stage,  the  prognosis  of  this  condition  is  good. 
Where  treatment  is  deferred  for  some  time  after  injury, 
the  prognosis  is  not  good.  The  articular  modifications 
brought  about  by  the  malposition  are  then  more 
difficult  of  reduction  ;  the  muscles  undergo  structural 
modification  and  are  less  easy  to  reiuce.  We  have 
never  yet,  however,  seen  an  incurable  case.  Moreover, 
as  in  the  case  of  myotonic  constriction,  we  have  never 
observed  trophic  derangements  analogous  to  those 
seen  in  acromyotonia,  which  so  singularly  darken  the 
prognosis  in  this  condition. 


CHAPTER    V 

MECHANICAL   TREATMENT 

I.     Elementary  Principles 

Before   entering  into   the   details   of   the   methods 
advocated  in  individual  cases  of  mandibular  fracture, 
it  is  expedient  to  indicate  briefly,  for  those  of  our 
readers  who  are  not  specialists,  the  principal  types 
of   apparatus  in   use   in   the   practice   of   prosthetic 
dentistry  as  well  as  the  results  obtainable  from  each. 
These   appliances   resemble    one   another   in   theii 
object,  which  is  to  replace  teeth  which  have  been  lost. 
They  differ  from  one  another  in  their  mode  of  anchor- 
age.    The  most  simple  form  may  be  removed  and 
cleansed  by  the  patient  himself  ;    this  is  termed  a 
removable  appliance.     It  consists  of   a   vulcanite   or 
metal  plate  covering  the  alveolar  ridges  or  the  palate 
to  an  extent  which  varies  with  the  number  of  teeth 
to  be  replaced.     The  artificial  teeth  are  attached  to 
this  plate  at  the  required  positions.     The  retention  of 
this  appliance  is  effected  by  means  of  hooks  round 
existing  teeth,  by  sliding  posts  attached  to  roots  or, 
where  the  jaws  are  totally  deprived  of  teeth,  by  lateral 
springs    uniting    the    two    artificial    rows.     Suction 

659 


660      FRACTURE  OF   THE  LOWER  JAW 


cavities  are  also  employed  for  upper  dentures.  These 
are  small  cavities  on  the  palatine  surface  of  the  plate  ; 
by  means  of  suction  the  patient  creates  a  void,  which 
immediately  brings  in  the  factor  of  atmospheric  pres- 
sure, by  which  the  plate  becomes  firmly  applied  to  the 
roof  of  the  mouth.     Rubber  washers  of  different  kinds 

are  sometimes  em- 
ployed to  reinforce  or 
facilitate  the  action  of 
these  suckers. 

The  prototype  of 
fixed  mechanism  is  the 
bridge.  This  is  a  rigid 
structure  to  which  the 
artificial  teeth  are  at- 
tached and  which  re- 
quires for  its  support  at 
least  two  sound  teeth. 
The  teeth  which  serve 
as  pillars  must  be  strong 


Fig.  38. — Complete  set  of  arti- 
ficial teeth.  Type  of  removable 
mechanism.  (The  stability  of  this 
apparatus  is  assured  by  the  springs 
on  each  side,  by  which  the  upper 
and  lower  dentures  are  united.  On 
the  palatine  surface  of  the-  upper 
mechanism  a  small  cavity  is  shown, 
known  as  the  sucker.  When  the 
mechanism  is  in  place,  the  patient 
creates  a  void  by  means  of  a  suck- 
ing movement  which  causes  the 
plate  to  adhere  to  the  palate.) 


and  healthy.  The 
method  of  anchorage  is  by  means  of  metal  caps  which 
cover  the  entire  crowns.  Where  roots  are  employed 
as  pillars,  metal  screws  are  used.  These  penetrate  as 
far  as  possible  into  the  root  canal,  which  has  previ- 
ously been  enlarged,  the  free  surface  of  the  root  being 
covered  by  a  cap.  In  addition  to  these  methods  of 
anchorage,  which  are  the  ones  most  in  general  use, 
gold  screw-blocks,  perforated  crowns,  etc.,  may  be 
employed.     It  is  not  necessary  to  describe  them  here. 


MECHANICAL  TREATMENT 


661 


Fig,  39. — Complete  appliance  for  the 
upper  jaw  with  india-rubber  sucker. 
(To  reinforce  the  action  of  the  sucker 
as  described  in  fig.  38  a  small  india- 
rubber  washer  (1)  is  employed.  It 
adheres  to  the  palate  in  the  manner  of 
a  cupping-glass.) 


The  platform  of 
the  bridge  is  com- 
posed of  metal,  and 
sufficient  space  is  left 
between  its  lower 
surface  and  the  gum 
to  permit  of  the 
bridge  being  cleansed 
in  situ.  The  appa- 
ratus is  permanently 
attached  to  its  an- 
chorage by  an  osteo- 
plastic cement.  Of  all  mechanisms  the  bridge  is  the 
one  which  permits  of  the  most  perfect  restoration  of 
function.  The  pillars,  however,  must  be  very  judici- 
ously chosen  and  prepared,  and  it  is  essential  that  dis- 
proportionate 
;:\\  demands  should 

not  be  made 
uponthem.  For 
this  reason, 
small  bridges 
carrying  not 
more  than  three 


a    - 


Fig.  40. — Bridge.  Type  of  fixed  apparatus. 
(The  first  molar  is  covered  by  a  mietal  cap  (1) ; 
the  root  of  the  canine  serves  as  support  for 
a  screw-cap  (2).  These  two  points  act  as 
pillars.  Between  them  stretches  the  platform 
of  the  bridge,  represented  in  the  drawing  by 
two  solid  crowns  which  replace  the  absent  pre- 
molars (3).  Between  the  platform  of  the  bridge 
and  the  gum  a  sufficient  interval  is  allowed  to 
permit  of  the  cleansing  of  the  mechanism.) 


teeth  are  the 
most  satisfac- 
tory. 

There  is  yet 
another  type  of 
mechanism 


662      FRACTURE  OF   THE  LOWER  JAW 

which  combines  the  methods  of  anchorage  of  the 
bridge  with  those  of  the  plate,  and  this  is  termed 
the  removable  bridge.  It  is  a  mechanism  designed 
by  us  for  the  treatment  of  median  pseudo-arthrosis. 
It  is  described  in  full  detail  in  a  later  chapter,  and 
to  that  we  refer  the  reader. 

The  description  of  these  three  types  of  apparatus 
shows  the  extent  to  which  teeth  which  have  been 
retained  may  be  employed.  The  principles  are  well 
known  to  stomatologists ;  they  serve  as  valuable 
guides  in  the  manufacture  of  the  numerous  mechanisms 
employed  in  the  treatment  of  fracture  of  the  jaw. 

Another  important  physiological  phenomenon,  and 
one  which  should  not  be  lost  sight  of,  is  the  extreme 
mobility  of  the  temporo-mandibular  joints  and  their 
wonderful  capacity  for  adaptation.  Examples  are 
constantly  furnished  by  modern  dentistry  and  ortho- 
dontics. 

II.    The  Immediate  Treatment  of  Lesions 

What  methods  should  be  employed  immediately 
after  injury  in  mandibular  fracture  ? 

The  large  majority  of  cases  might  undoubtedly  be 
immediately  transferred  to  special  centres  at  the  base 
for  the  treatment  of  maxiUo-facial  injury.  These 
comprise  the  less  serious  lesions,  the  incomplete  frac- 
tures, and  the  complete  fractures  with  little  or  no  loss 
of  substance.  Such  cases  have  all  passed  through  a 
field  station.  The  wounds  of  exit  and  of  entry  have 
been  dressed  and  drainage  of  the  integumental  side, 


MECHANICAL  TREATMENT  (503 

where  necessary,  has  been  effected.  At  the  evacuation 
hospitals  where  there  is  usually  provision  for  stomato- 
logical treatment,  the  preliminary  treatment  just 
referred  to  can  be  supplemented  by  thorough  cleansing 
of  the  buccal  cavity,  and  by  the  application  of  a  four- 
tailed  bandage  or  suitable  sling  to  give  temporary 
rest  to  the  fragments.  In  lieu  of  the  four-tailed  ban- 
dage an  Angle's  arch  may  when  possible  be  adjusted. 
This  mechanism  provides  an  excellent  means  of  obtain- 
ing an  emergency  immobilisation.  It  is  a  kind  of 
general  appliance  which  may  be  adapted  to  each 
particular  case,  and  every  evacuation  hospital  should 
be  well  provided  with  it.  To  the  practised  stomatolo- 
gist its  attachment  requires  half  an  hour  at  the  most, 
and  the  slight  fatigue  experienced  by  the  patient  after 
the  manipulation  is  completed  is  amply  compensated 
for  by  the  comfort  experienced  during  the  rest  of  the 
journey.  Such  cases  arrive  at  the  base  in  excellent 
condition.  Their  diagnosis  papers  should  be  marked 
"  evacuation  at  a  centre  for  facio-maxillary  treat- 
ment," which  greatly  facilitates  their,  distribution 
among  the  hospitals  of  the  interior. 

All  cases  in  which  the  lesion  is  at  all  grave  should 
be  kept  for  a  time  at  the  front.  It  is  in  these  cases, 
which  are  too  varied  and  complex  for  description  here, 
that  complications  are  most  likely  to  arise.  Such  are : 
primary  and  secondary  haemorrhage  of  the  lingual, 
facial,  •  external  carotid,  and  internal  maxillary  and 
its  branches ;  traumatic  shock ;  asphyxia  from  divi- 
sion   of    the    genio-glossal    muscles    and    consequent 


664:     FRACTURE  OF   THE  LOWER  JAW 

descent  of  the  tongue  into  the  pharynx  ;  primary 
infective  conditions  ;  and  secondary  broncho-pulmon- 
ary, gastro-intestinal,  and  general  infective  con- 
ditions. 

We  do  not  propose  to  enter  into  the  details  of  either 
a  stimulant  medication  or  its  indications. 

By  surgical  drainage  of  the  tract,  in  accordance 
with  the  methods  of  general  surgery,  it  is  possible  not 
only  to  reduce  the  local  infective  conditions,  but  to 
discover  and  to  ligature  arteries  which  have  been  laid 
bare  and  which  are  liable  to  prove  a  source  of  secon- 
dary haemorrhage. 

Early  resection  of  the  bone  should  be  avoided.  Free 
splinters  should  be  removed,  as  well  as  bony  frag- 
ments, portions  of  teeth,  and  projectiles  situated  in 
the  soft  parts.  In  order  to  prevent  incessant  flow  of 
saliva  and  to  facilitate  feeding,  it  is  sometimes  neces- 
sary to  perform  emergency  operations  of  a  plastic 
nature  upon  the  teeth  and  lips.  This  is  a  resource, 
however,  which  should  be  employed  with  great  dis- 
cretion and  under  conditions  only  which  permit  of  the 
efficient  drainage  of  the  wound. 

To  guard  against  asphyxiation,  a  silk  thread  should 
be  passed  through  the  tip  of  the  tongue  and  attached 
to  the  dressing  by  means  of  an  adhesive  strap.  This 
method  allows  the  tongue  to  be  drawn  forward  and 
kept  in  position.  The  performance  of  trachaeotomy 
cannot  be  too  strongly  condemned.  Not  only  is  it 
entirely  useless  in  the  circumstances,  but  it  is  extremely 
dangerous,  for  it  creates  a  port  of  entry  in  the  near 


MECHANICAL   TREATMENT 


Q^b 


proximity  of  an  extremely  septic  area  from  which 
infection  is  very  liable  to  spread. 

The    stomatologist    on    his    side    should    see    that 
the  buccal  cavity  is  kept  scrupulously  clean.     Only 
absolutely    necessary    extractions    should    be    made, 
however,  for  it  is  essential  that  the  state  of  shock 
should      not      be 
augmented.  Tem- 
porary  treatment 
should  be  confined 
to      making     the 
patient     comfort- 
able.    Sedative 
dressings     should 
be  applied  to  the 
surfaces  of    teeth 
which   have   been 
broken,    exposing 
the    dental    pulp. 
The  fragments  of 
bone     should     be 
immobilised  by  means  of  mechanisms  which  are  easy 
of   adjustment.     Angle's   arch    (fig.    49),    interdental 
and  intermaxillary  ligature  are  the  measures  recom- 
mended (fig.  41). 

On  the  recommendation  of  Pont  a  simple  pocket-case 
of  instruments  has  been  adopted  by  the  medical 
service,  which  renders  the  adjustment  of  Angle's  arch 
a  very  simple  manoeuvre  ;  one,  moreover,  which  may 
be  employed  at  a  stationary  ambulance  or  at  an  evacua- 


FiG.  41. — Extemporary  method  of 
obtaining  immobilisation  in  occlusion. 
(Ligatures  of  brass  wire  are  slipped  round 
the  necks  of  a  certain  number  of  corre- 
sponding teeth  of  both  jaws.  The  ends 
are  then  interunited,  the  result  being  a 
perfect  immobilisation  of  the  mandibular 
fragments.) 


666     FRACTURE  OF   THE  LOWER  JAW 

tion  hospital.  This  pocket-case  contains  three  Angle's 
arches,  a  pair  of  flat  pliers,  a  pair  of  scissors,  a  file, 
and  a  wrench. 

It  is  most  important  that  profuse  irrigation  by  a 
douche  be  carried  out  three  or  four  times  a  day.  Per- 
manganate 1  in  8,000  and  nitrate  of  silver  1  in  20,000 
are  the  best  solutions. 

It  is  a  wise  precaution  to  feed  these  patients  by  a 
naso-pharyngeal  tube.  In  this  class  of  case,  move- 
ments of  deglutition  are  invariably  both  pairiful  and 
awkward. 

Sebileau  states  that  patients  have  come  under  his 
notice  upon  whom  gastrostomy  had  been  performed. 
This  operation  is  never  indicated  except  where  the 
simple  apparatus  necessary  for  oesophageal  catheterism 
is  lacking. 

III.     Mechanical  Treatment  of  Fractures 

The  management  of  mandibular  fracture  involves 
two  problems  :  to  obtain  a  good  union  on  the  one 
hand  and,  on  the  other,  to  maintain  or  to  restore  the 
occlusion,  for  this  is  essential  to  good  mastication. 

In  a  case  of  simple  contact  fracture  without  loss 
of  substance,  this  double  object  is  readily  fulfilled. 
Where  there  is  loss  of  substance  the  problem  is  a  more  . 
delicate  one.  How  is  a  good  union  with  satisfactory 
callus  to  be  effected  when  the  fragments  are  separated 
by  an  interval  of  varying  extent  ?  On  the  other  hand, 
admitting  the  possibility  of  effecting  a  union,  how  is 
function  to  be  preserved  ? 


MECHANICAL  TREATMENT  C67 

Certain  surgeons,  in  pursuance  of.  the  principle 
advocated  formerly  by  Claude  Martin,  make  their 
objective  the  re-establishment  of  the  occlusion  of  the 
teeth.  Their  method  consists,  whatever  the  extent  of 
the  breach,  in  immobilising  the  mandibular  fragments 
in  such  a  way  that  the  inferior  teeth  preserve  their 
articulation  with  those  above  them.  Martinier  and 
Lemerle,  in  a  work  which  appeared  in  1915,  describe 
the  method  as  foUows  : 

"  After  a  loss  of  substance  sufficient  to  produce 
shortening  of  the  mandible,  the  fragments  should  be 
regularised  and  the  case  should  be  handled  as  in  partial 
resection  of  the  bone.  A  block  of  vulcanised  india- 
rubber  inserted  into  the  wound  prevents  cicatricial 
retraction.  When  the  epidermal  covering  of  the  scar 
is  complete,  the  block  is  replaced  by  an  ordinary  mobile 
dental  apparatus  the  base  of  which,  by  filling  the 
cavity  formerly  occupied  by  the  lost  fragment  of  bone, 
assures  the  continuity  of  the  mandible." 

The  method  of  treatment  by  the  immediate  employ- 
ment of  mechanical  contrivances  could  not  be  better 
described,  nor  could  its  advocates  more  clearly  demon- 
strate their  attachment  to  the  principles  advocated 
by  Claude  Martin. 

It  is  not  possible  for  us  to  identify  ourselves  with 
these  views.  The  regularisation  of  the  fractured  sur- 
faces and  the  removal  of  splinters,  some  of  which 
may  have  retained  their  periosteum  and  thus  their 

^Martinier  and  Lemerle,  Prothese  reatauratrice  huccofaciale, 
J.  B.  Bailliere.  1915. 


668      FRACTURE  OF   THE  LOWER  JAW 

vitality,  appears  to  us  contrary  to  sound  surgical 
principles.  Further,  how  will  the  patient  bear  the 
immediate  application  of  a  mechanism,  which  is 
bound  to  retard  the  cicatrisation  of  the  wound  and 
which  must  induce  septic  conditions  of  the  buccal 
cavity,  exposing  him  over  a  long  period  of  time  to  the 
dangers  of  broncho-pulmonary,  gastro-intestinal,  or 
general  infection  ? 

Even  more  deplorable  in  our  view  is  the  result 
aimed  at,  for  all  that  the  method  can  hope  to  achieve 
is  a  pseudo-arthrosis.  We  know  that  eventual  mecha- 
nical treatment  is  able  to  effect  a  certain  solidarity 
between,  the  mandibular  fragments  and  to  re-estab- 
lish, to  a  certain  extent,  the  masticatory  function. 
But  one  cannot  fail  to  recognise  that  the  result  is 
a  transitory  one,  the  period  of  usefulness  of  such 
mechanisms  being  dependent  upon  the  preservation 
of  the  teeth.  The  latter,  serving  as  they  do  as  points 
of  anchorage,  undergo  a  supplementary  strain  which 
is  not  calculated  to  prolong  their  duration,  and  irre- 
mediable infirmity  must  sooner  or  later  show  itself. 

It  does  not  seem  that  Martinier  and  Lemerle's 
technique  has  been  very  frequently  employed.  On  the 
other  hand,  we  know  that  the  re-establishment  of 
normal  dental  occlusion  forms  the  chief  aim  of  many 
stomatologists,  who  are  content  to  immobilise  a  frac- 
tured mandible  in  good  occlusion  without  troubling 
about  the  co-adaptation  of  the  bony  fragments. 

Where  the  loss  of  bony  substance  is  small,  the  method 
has  much  to   recommend  it,  for  union  under  such 


MECHANICAL  TREATMENT  669 

conditions  almost  invariably  follows  its  employment. 
Even  in  cases  where  the  loss  of  bony  substance  is 
considerable,  namely,  2-3  centimetres,  the  fragments 
have  been  known  to  unite  as  the  result  of  simple 
immobilisation.  Whether  in  these  cases  some  shreds 
of  periosteum  remained  intact,  or  whether  destruc- 
tion was  not  as  extensive  as  it  appeared  to  be,  is 
not  known.  In  spite  of  these  results,  it  is  none  the 
less  true  that  in  this  class  of  case,  treated  in  this 
manner,  union  is  exceptional  and  can  never  be  safely 
predicted. 

The  methods  which  we  ourselves  advocate  have 
for  their  chief  object  the  prevention  of  pseudo-arthro- 
sis.  As  will  be  shown  later,  the  object  is  usually  to 
establish  the  co-adaptation  of  the  fragments,  even  at 
the  price  of  mandibular  deformity.  It  is  not  essen- 
tial that  the  mandible  should  reacquire  its  anatomical 
outline  for  a  satisfactory  occlusion  with  restoration 
of  function  to  be  established.  As  we  have  shown  in 
another  place  ^  it  is  always  possible  to  correct  or  to 
compensate  for  the  deformity. 

Restorative  mechanisms  are  employed  only  to  remedy 
very  extensive  pseudo-arthroses,  and  then  only  when 
surgical  measures  have  failed. 

In  view  of  the  conditions  peculiar  to  mandibular 
fracture  and  the  complex  problems  associated  with 

1  Imbert  and  R6al,  "Les  fractures  laterales  de  la  machoire 
inf6rieure  avec  p^lie  de  substance,"  Odontologie,  September  30th, 
1916. 


670      FRACTURE  OF  THE  LOWER  JAW 

its  treatment,  certain  authors  have  found  it  expedient 
to  treat  these  lesions  on  special  therapeutic  lines. 

Cavalie  proposes  "a  general  anatomical  clinical 
treatment  divided  into  three  periods." 

First  period. — Restoration  of  the  mandibular  arch 
either  by  surgical  means,  by  mechanism,  or  by  the 
simultaneous  employment  of  both  methods. 

Second  'period. — Orientation  of  the  arch  by  surgical 
or  mechanical  means  or  by  both. 

Third  period. — Temporary  and  permanent  adjust- 
ment of  mechanical  appliances. 

Frey  ^  describes  four  stages  in  the  treatment  of 
mandibular  fracture.  The  first  stage,  that  of  orthogna- 
thia, has  for  its  object  the  re-establishment  of  the 
normal  relationships  between  the  teeth  and  the  jaw. 
The  second  stage,  that  of  contention,  consists  in  the 
maintenance  of  the  fragments  in  the  conditions  of 
normal  intermaxillary  and  interdental  relationship 
which  have  already  been  established.  The  third  stage 
comprises  dynamic  exercises,  the  stomatologist  en- 
deavouring to  re-establish  the  synergy  of  the  mastica- 
tory muscles  and  to  overcome  the  retraction  of  the 
cicatrices.  The  fourth  stage  is  that  of  mechanical 
replacement  or  prosthesis  (from  the  Greek,  /  replace). 

The  physiological  method  advocated  by  G.  Villain " 
does  not,  as  a  matter  of  fact,  introduce  a  fresh  thera- 

*■  Frey,  "Un  aper9U  de  la  prothese  restaviratrice  dans  les  fractures 
des  machoires  et  mutilations  de  la  face,"  Paris  medical,  August  21st, 
1915. 

2  Geo.  Villain,  "Traitement  physiologique  des  fractures  et  des 
luxations  dumaxillaireinferieur,"  Odontologie,  July  and  August,  1910. 


MECHANICAL  TREATMENT  671 

peutic  idea.  This  author  advises,  and  very  justly, 
the  systematic  employment  of  the  movements  and  of 
the  tonicity  of  the  muscles  as  forces  of  reduction  and 
contention.  In  this  connection  he  advocates  the 
crank,  an  excellent  apparatus  to  which  we  shall  return 
later. 

From  our  point  of  view  all  these  authors  possess 
the  same  fault,  namely,  that  of  making  the  restoration 
of  dental  occlusion  their  primary  object,  union  of  the 
fragments  being  given  a  secondary  place.  Moreover, 
surgeons  who  have  been  disappointed  in  the  results 
of  special  technical  methods  are  not  likely  to  accept 
willingly  yet  another  special  therapy  and  a  fresh 
terminology.  For  this  reason  we  shall  continue  to 
employ  the  terms  "  reduction  "  and  "  contention," 
the  significance  of  which  is  well  known  and  their 
employment  in  connection  with  general  surgery 
universal.  By  "  reduction  "  we  mean,  not  only  the 
co-adaptation  of  the  fragments  witii  the  object  of 
effecting  a  satisfactory  union,  but  also  the  establish- 
ment of  an  occlusion  which  will  permit  of  satisfactory 
mastication.  It  is  only  in  extreme  cases  accompanied 
by  considerable  loss  of  substance,  where  it  is  impossible 
to  bring  the  fractured  surfaces  together,  that  "  reduc- 
tion "  is  confined  to  the  re-establishment  ot  normal 
dental  articulation.     • 

In  recent  fractures,  that  is  to  say,  those  in  which 
the  processes  of  bony  repair  are  not  far  advanced, 
early  reduction  is  readily  obtainable.  Treatment  is 
confined   to   the   employment   of   on   immobilisation 


672      FRACTURE  OF   THE   LOWER  JAW 

apparatus,  constructed  by  special  methods  upon  a 
model  of  the  jaw  modified  by  the  form  which  it  is 
desired  to  produce. 

In  old  fractures  rapid  correction  of  the  deviations 
and  deformities  of  the  mandible  is  not  possible.  These 
cases  necessitate  the  employment  of  mechanisms  the 
action  of  which  is  more  or  less  gradual,  and  which 
are  not  replaced  by  passive  appliances  for  contention 
until  the  jaws  have  recovered  their  normal  relation- 
ship. The  statement  of  this  general  principle  is 
necessary  to  a  complete  understanding  of  the  following 
chapter,  in  which  the  methods  of  reduction  and 
retention  to  be  employed  in  each  type  of  fracture  are 
described. 

The  mechanisms  described  are  either  those  which 
we  ourselves  most  commonly  employ,  or  those  which 
in  the  hands  of  others  have  given  the  most  satisfactory 
results.  It  may  seem  a  little  surprising  that  no 
mention  is  made  of  earlier  mechanisms,  especially 
those  with  extra-buccal  attachment  employed  by 
Claude  Martin,  Kingsley,  Richet,  etc.  As  a  matter 
of  fact,  these  have  practically  disappeared  from 
modern  maxillo-facial  practice.  Those  of  our  readers 
who  desire  further  information  concerning  them 
should  consult  Martinier  and  Lemerle's  book  on  the 
subject,  to  which  reference  has.  already  been  made. 

Before  passing  to  a  detailed  account  of  our  own 
methods,  it  is  expedient  to  give  the  therapeutic  classifi- 
cation formulated  by  Sauvez,  the  scheme  of  which  is 
very  sound  and  which  we  have  very  largely  adopted. 


MECHANICAL  TREATMENT 


673 


Table  of    Treatment  in    Mandibular    Fracture 

FIRST    CLASS 
Each   fragment   contains   teeth   (median   or   paramedian  fracture) 

First  Division 
Without  loss  of  substance 
Case  1  : 
No  displacement.  Mechanical  treatment.     Jaws 


Case  2  : 

Displacement. 


Mechanical  treatment, 
not  ligatured  together. 

Mechanical  treatment, 
not  ligatured  together. 


Jaws 


Second  Division 
With  loss  of  substance 
Case  1  : 

Loss  slight.  Union  of  frag- 
naents  effects  a  tolerable  occlu- 
sion. 


Mechanical  treatment, 
not  ligatured  together. 


Case  2  : 

Loss  comparatively  large. 
Union  does  not  effect  occlusion, 
but  this  may  be  done  by  means 
of  a  fixed  bridge  in  one  or  three 
parts. 

Case  3 : 

Loss  very  extensive.  It  is 
impossible  to  employ  a  fixed 
bridge. 


Mechanical  treatment, 
not  ligatured  together. 


Jaws 


Jaws 


1st.  Mechanical  treatment. 
Jaws  not  Ugatured  together. 

2nd.  Mechanical  treatment. 
Jaws  not  ligatured  together. 

3rd.  Surgical  treatment. 
Jaws  ligatured  together. 


SECOND    CLASS 

One  fragment  is  toothless  (retrodental  fracture  and  fracture  of  the 

ramus) 

FiBST  Division 
Without  loss  of  substance 


Case  1  : 

No  displacement. 

Case  2  : 

Displacement. 


Mechanical  treatment.  Jaws 
ligatiired  together. 

Combined  surgical  and 
mechanics!  treatment  (plate). 
Jaws  hgatured  together. 


674      FRACTURE  OF  THE  LOWER  JAW 

Second  Division 
With  loss  of  substance 

Case  1  : 

Slight  loss.      Union  effects  a  Treatment  either  surgical  or 

tolerable  occlusion.  mechanical  (plate).     Jaws  liga- 

tured together. 
Case  2  : 

Extensive     loss.      Union     is  Surgical  treatment.     Jawliga- 

either  impossible,  or,  if  effected,       tured  together. 
would  not  bring  about  occlusion.  Mechanical    treatment,    tem- 

porary or  permanent.     Jaws  not 
ligatured  together. 

Preparatory  Treatment. — ^No  decision  in  regard  to 
treatment  should  be  made  until  a  good  skiagram  of  the 
lesion  has  been  obtained,  not  only  in  order  to  facilitate 
diagnosis  but  in  order  to  ascertain  the  condition  of 
the  site  of  the  fracture.  It  is  also  absolutely  essential 
that  the  mouth  be  carefully  prepared  before  institut- 
ing a  mechanical  therapy. 

After  the  buccal  cavity  has  been  minutely  cleansed 
and  infected  roots  have  been  extracted,  the  fracture 
site  should  be  examined  with  particular  care.  Frag- 
ments of  roots  of  teeth  are  sometimes  present,  and 
these  considerably  retard  union.  Some  very  striking 
cases  of  this  kind  have  passed  through  our  hands. 
Roots  included  in  the  region  of  the  fracture  are  well 
shown  by  skiagrams.  They  are  those  of  teeth  adjoin- 
ing the  fracture  site,  and  they  appear  to  plunge  down 
into  it.  Not  only  should  remains  of  roots  be  extracted, 
but  also  teeth  the  denuded  roots  of  which  might 
convey  to  the  site  of  fracture  infection  from  the  buccal 

area. 

Patients  frequently  come  in  who  are  in  an  emaciated 
and   weakened   condition ;    the   way   in   which   they 


MECHANICAL   TREATMENT  675 

respond  to  general  treatment  is  very  striking.  Our 
method  is  to  give  two  Ferrier's  cachets  ^  a  day,  to 
which  fifteen  drops  of  adrenalin  solution,  1  in  1,000, 
are  added  (Sergent,  Presse  medicale,  1913,  No.  93). 

This  recalcifiant  {medication  recalcifiante)  treat- 
ment is  pursued  for  ten  days  at  a  time,  with  intervals 
of  ten  days. 

The  general  condition  improves  very  rapidly  under 
this  treatment,  which  has,  presumably,  a  definite 
action  in  promoting  the  growth  of  the  callus.  The 
work  of  P.  Carnot  and  C.-L.  Slavu  (C.  R.  de  la  Societe 
de  Biologic,  1900,  vol.  Ixviii.  p.  832)  upon  the  influence 
of  adrenaline  upon  bony  repair  and  the  growth  of 
the  callus  is  interesting  in  this  connection.  These 
authors  are  entirely  in  favour  of  the  method. 

Care  must  be  taken  during  the  entire  period  of 
treatment  to  keep  the  mouth  in  a  state  of  absolute 
cleanliness.  Every  patient  should  clean  his  teeth 
with  soap  at  least  twice  a  day.  Irrigation  by  means 
of  a  douche  should  be  performed  as  frequently  as 
the  condition  of  the  lesions  demands.  Permanganate 
1  in  8,000,  and  nitrate  of  silver  1  in  20,000,  are  the 
best  solutions  for  this  purpose. 

The  problem  of  feeding  is  solved  in  the  following 
manner.  Those  patients  whose  jaws  are  not  immo- 
bilised, as  well  as  those  whose  jaws  are  kept  closed, 

^  Ferrier's  cachets  : 

Precipitated  calcium  phosphate        .  .     0'50  centigr. 

Calcium  carbonqite  .  .  .0*30 

Sodium  chloride     .....     0"15 
Calcined  magnesia .  .  .  .     0"10        ,, 


676      FRACTURE   OF   THE  LOWER  JAW 

are  given  a  liquid  or  semi-liquid  diet  consisting  of 
minced  meat,  vegetable  puree,  prepared  foods,  thick 
soups,  milky  foods,  and  eggs.  Neither  at  the  Hotel 
Dieu,  Marseilles,  nor  at  the  Hospice  de  Sainte  Mar- 
guerite, where  we  had  the  care  of  200  to  250  patients, 
have  we  ever  had  any  difficulty  with  this  diet. 
Patients  do  very  well  on  it.  In  certain  severe  cases, 
which  came  to  the  hospital  in  a  very  debilitated  con- 
dition, the  increase  of  weight,  namely  8|  lbs.  in  four- 
teen days,  was  really  remarkable.  The  Ferrier  cachets 
were  of  course  administered  simultaneously. 

As  soon  as  patients  are  fitted  with  their  retention 
mechanisms  they  are  usually  able  to  eat  the  hospital 
diet. 

^.Anterior  group:  Median  and  Paramedian  Fracture. 
— The  deformities  characteristic  of  these  fractures 
have  already  been  described. 

The  therapeutic  indications  vary  in  accordance  with 
the  amount  of  substance  lost.     It  may  be  small,  1  to* 
1|  cm.  ;    medium,    1|  to  3  cm.  ;    or  large,    3|  cm. 
and  over.     The  extent  of  the  loss  is  revealed  by  the 
degree  of  deformity  and  by  skiagrams. 

1,  Recent  Anterior  Fracture. — {a)  Slight  loss  of  sub- 
stance (up  to  1|  cm.).  The  method  here  is,  first  to 
restore  the  mandible  to  its  original  form  and  then  to 
immobilise,  the  procedure  being  as  follows  : 

A  good  model  of  the  jaws  is  made,  preferably  in 
plaster.  The  model  of  the  lower  j aw  is  sawn  in  two  along 
the  line  of  fracture.  Each  portion  is  then  brought 
into  normal  occlusion  with  the  teeth  of  the  upper 


MECHANICAL   TREATMENT 


677 


jaw.  To  a  stomatologist  the  task  is  an  easy  one. 
Normal  occlusion  being  established,  the  two  portions 
of  the  lower  jaw  are  fixed  in  position  by  means  of 
plaster.     The  model  of  the  mandible  as  it  was  before 


Figs.  42  and  43. — 
Double  splint  with  an- 
chor bands  for  the  im- 
mobilisation of  median 
or  paramedian  fracture 
with  slight  loss  of  sub- 
stance. (1,  2,  1',  2', 
are  four  German  sil- 
ver bands,  accurately 
adapted  and  attached  to 
the  crowns  by  cement. 
They  form  a  solid  an- 
chorage for  the  anterior 
and  posterior  sphnts, 
3  and  4,  which  are 
soldered  to  them.  These 
sphnts  are  of  cast  sil- 
ver, and  cover  only 
about  a  third  of  the 
crowns,  leaving  the  tri- 
turating surfaces  and 
the  necks  free.  The 
apparatus  may  be  ren- 
dered removable  by 
replacing  the  soldered 
anchor  bands  with  bands 
fastened  with  a  screw 
and  nut.  See  figs,  50 
and  51.) 


injury  is  thus  obtained,  and  the  mechanism  for  immo- 
bilisation is  constructed  on  the  model. 

The  method  which  we  recommend  is  the  double 
splint  with  anchor  bands  shown  in  figs.  42  and  43. 

The  absolute  immobility  conferred  by  this  mechan- 
ism is  due  not  only  to  the  method  of  anchorage  but 
also  to  the  splints  themselves  which,  where  requisite, 
may  be  ligatured  to  the  teeth. 


678       FRACTURE  OF   THE   LOWER  JAW 


The  anterior  and  posterior  splints  only  partially 
cover  the  crowns  of  the  teeth,  the  upper  and  lower 
thirds  remaining  free,  thus  facilitating  both  cleansing 
and  control.  The  splints  are  easily  removed  either 
by  cutting  the  bands  or  by  unsealing  the  cement. 

This  mechanism  is  infinitely  superior  to  the  type 
of  cast  silver  splint  shown  in  fig.  44,  which  has  the 

drawback  of  cover- 
ing practically  the 
whole  of  the  crowns 
as  well  as  a  portion 
of  the  muco-perio- 
steum. 

The  cap  splint  in 
two  pieces  is  a  me- 
chanism designed  to 
facilitate  supervision 
of  the  fracture  with- 
out the  necessity  of 
removing  the  me- 
chanism. The  two  pieces  are  separated  and  united 
at  will  by  means  of  a  special  contrivance.  The 
mechanism  shown  in  fig.  45  is  a  perfect  expression 
of  this  principle.  It  is  described  by  Dr.  Sauvez  and 
constitutes  a  very  happy  modification  of  the  open  splint. 
Double  splints  in  cast  metal,  attached  posteriorly 
by  means  of  a  hinge  and  connected  at  intervals  by 
screw-bolts,  may  also  be  used  for  the  purpose. 

Figs.  53,  54,  and  55  show  a  mechanism  designed  to 
effect  this  method  of  anchorage.     The  principle  is  that 


Fig,  44. — Open  splint  of  casf,  silver  for 
the  immobilisation  of  median  or  para- 
median fracture.  This  cap  splint  leaves 
the  occluding  surfaces  of  the  teeth  free. 


MECHANICAL  TREATMENT 


679 


of  adjustable  bands,  a  common  technical  device  in 
dental  surgery  and  one  that  has  been  imported  into 
the  therapeutics  of  mandibular  fracture.  It  is  unneces- 
sary to  enter  here 
into  the  details  of 
its  construction. 

The  soldered 
bands  shown  in 
fig.  42  may  be  re- 
placed by  adjustable 
bands  similar  to 
those  described  on  a 
later  page  in  con- 
nection with  Angle's 
arch.  This  method 
of  anchorage  renders 
the  splint  removable. 

(b)  Medium  loss  of 
substance  (li  cm.). — 
In  this  class  of  case 
compensatory  con- 
traction must  be  al- 
lowed for  and  union 
is  more  favourable  if 
the    fragments    are 


Figs.  45  and  4G. — Metal  splint  in 
two  pieces.  (This  splint  is  sawn  in 
two  at  the  fracture  site.  The  two  por- 
tions are  firmly  united  by  means  of 
bolts.  The  two  anterior  bolts,  1  and 
2.  of  which  one  is  threaded  to  form  a 
screw,  prevent  vertical  displacement. 
The  posterior  U-shaped  bolt  prevents 
horizontal  separation  of  the  fragments. 
The  mechanism  is  designed  by  Dr. 
Sauvez.) 


not  immobilised  in 
their  position  of  normal  occlusion.  The  model  on 
which  the  immobilisation  apparatus  is  constructed 
should  not  therefore  exactly  conform  to  the  normal 
shape  of  the  jaw,  but  it  should  to  a  certain  extent 


G80      FRACTURE  OF   THE  LOWER  JAW 

reproduce  the  deformity  characteristic  of  the  fracture. 
It  should,  however,  correct  the  tilting  inwards  of  the 
occlusal  surfaces  of  the  molars,  which  is  sometimes 
very  marked. 

An  immobilisation  apparatus  constructed  upon  such 


Fig.  47. — ^Immobilisation  of  median  fracture  with  large  loss  oi 
substance.  (Anchor  bands  are  cemented  to  the  molars  A,  B,  C, 
D,  E.  They  are  soldered  together  and  rendered  stable  by  two 
rigid  rods  F  F',  thus  assuring  the  immobilisation  of  the  fragments 
and  maintaining  them  in  their  normal  position.) 


a  model  will  result  in  union  with  slight  contraction. 
The  contraction  is  readily  remedied  by  various  ortho- 
dontic measures  for  obtaining  mandibular  expansion. 

Correction  of  the  contraction  should  not  be  deferred 
until  after  ossification  of  the  callus.  It  should  he 
undertaken  at  the  moment  when  the  mobility  of  the  frag- 


MECHANICAL  TREATMENT  681 

menls  appears  to  be  arrested  by  the  resistance  of  the 
callus,  while  skiagrams  show  that  ossification  is  not  as 
yet  very  far  advanced.  Intervention  at  this  moment 
IS  attended  by  results  which  are  positively  astounding. 
Some  years  ago  Monod  published  an  account  of  a 


Fig.  48. — Apparatus  for  the  immobilisation  of  median  fracture 
with  large  loss  of  substance.  (The  lateral  fragments  are  extremely 
mobile,  which  necessitates  a  very  firm  method  of  anchorage.  The 
anchor  bands  are  replaced  by  crowns  (1,  2,  3,  1',  2',  3')  which  are 
soldered  together.  The  interior  surfaces  of  these  crowns  are 
furnished  with  studs  or  screws  which  penetrate  the  palp  cavities 
or  even  the  posterior  roots.  The  anchor  blocks  are  united  by 
two  transverse  bars.  The  vulcanite  piece  (4)  serves  as  guide  for 
cheiloplastic  operation.  It  is  attached  to  the  principal  mechanism 
by  two  parallel  rods  running  in  two  tubes.  After  cheiloplastic 
intervention  this  apparatus  may  be  used  as  an  extensor  for  the  Up.) 

case  which  is  very  significant  in  this  connection.  He 
effected  extension  of  the  callus  with  the  object  of 
reducing  a  marked  contraction  of  the  jaw.  The  ulti- 
mate union  was  in  no  way  impeded ;  in  fact,  it  almost 
seemed  as  if  the  extension  of  the  callus  had  exercised 
a  stimulating  effect  upon  the  osteo-genetic  processes. 


68^      FRACTUBE  OF   THE  LOWER  JAW 

More  recently,  at  the  Interallied  Dental  Congress, 
Caumartin  and  Valadier  described  cases  of  prolonga- 
tion of  the  callus  with  perfect  union.  The  mechanism 
which  Ave  ourselves  employ  for  this  purpose  is  shown 
in  fig.  52  and  will  be  described  later. 

It  is  easy  to  compensate  for  slight  contraction  by 
the  m.ethod  known  as  "  jumping  the  bite."  This  is 
a  manipulation  practised  by  many  stomatologists  and 
is  carried  out  by  means  of  a  variety  of  mechanisms 
into  the  details  of  which  it  is  not  necessary  to  enter  here. 

(c)  Large  loss  of  siihstance  (3  cm.  and  over). — The 
breach  is  here  too  large  to  be  compensated  for  by  the 
union  of  the  fragments.  All  that  can  be  done  is  to 
maintain  the  fragments  in  normal  position  until  after 
the  cicatrisation  period  (figs.  47  and  48).  Later 
they  are  united  by  a  bony  graft,  or  by  a  restorative 
mechanism  in  the  manner  of  Claude  Martin. 

2,  Old  Anterior  Fracture. — For  the  correction  of 
deviations  which  it  is  impossible  to  reduce,  we  usually 
employ  Angle's  alignment  wire,  a  very  common  appli- 
ance in  orthodontics. 

Angle's  apparatus  consists  of  : 

1.  A  German  silver  alignment  wire  with  threaded 
ends  fitted  with  nuts. 

2.  Two  anchor  bands  of  the  same  metal,  to  the 
buccal  surface  of  which  tubes  are  attached,  into  which 
the  extremities  of  the  alignment  wire  are  slipped. 

Application  of  the  Mechanism. — ^The  anchor  bands 
are  attached  to  the  first,  or,  if  these  are  missing,  the 
second  molars.     The  arch  is  placed  in  front  of  the 


MECHANICAL   TREATMENT 


f;,s; 


teeth  in  such  a  way  that  the  anterior  curve  is  in 
contact  with  the  incisors.  All  the  teeth  in  contact 
with  the  wire  arch  are  then  attached  to  it  by  ligatures, 
which  are  passed  through  the  interdental  spaces  and 
tied.     The  alignment  wire  should  not  be  fitted  to  the 


Fig.  49. — Angle's  apparatus  for  paramedian  fracture.  (The 
line  X  X'  represents  the  fracture  site.  The  apparatus  consists  of 
a  German  silver  arch  A,  running  in  two  tubes  B  B',  attached  to 
two  screw  bands  G  G'.  The  anchor  bands  are  attached  to  the 
first  molars.  All  the  teeth  in  contact  with  the  alignment  wire 
are  attached  to  it  by  brass  wire  ligatures  passed  through  the  inter- 
dental spaces.  The  extremities  of  the  alignment  wire  are  threaded 
and  furnished  with  screws  placed  at  the  anterior  extremities  of  the 
tubes. ) 

lingual  surfaces  of  the  teeth.  It  should  be  given  a 
parabolic  form,  which  is  the  ideal  mandibular  outline, 
and  to  which  the  amended  jaw  will  conform. 

The  method  of  action  is  briefly  as  follows  :    In  the 


684      FRACTURE  OF   THE    LOWER  JAW 

first  place,  the  elasticity  of  the  metal  tends  to  straighten 
out  the  dental  arch  and  thus  to  separate  the  two 
fragments  to  which  it  is  attached.  In  the  second, 
by  tightening  the  brass  wire  ligaments  attached  to 
the  teeth  implanted  in  the  fragments,  it  is  possible 
gradually  to  draw  the  latter  towards  the  alignment 


Fios.  50  aTii!  51. — Detailrf  of  the  oxtremities  of  Angle's  arch. 
[D  I)'  nuts;  B  B'  tubes  eoiitnining  the  extremities  of  the  arch. 
Fig.  50  shows  tlio  method  of  applying  the  brass  wire  ligatures. 
Fig.  51  shows  the  manner  of  tightening  the  nut  by  means  of  the 
special  screw -key  ) 


wire,  thus  restoring  the  normal  dental  alignment. 
Finally,  by  tightening  the'  nuts  against  the  anterior 
extremities  of  the  tubes,  the  diameter  of  the  align- 
ment wire  is  increased  and  it  is  forced  in  consequence 
to  expand  transversely  (fig.  49). 

The  alignment  wire  is  an  excellent  mechanism  in 
this  condition,  where  it  is  a  question  of  mobilising  two 
fragments  of  approximately  the  same  size,  subjected 


MECHANICAL   TREATMENT 


GS5 


to  muscular  influences  which  are  approximately  equal , 
and  which  produce  convergent  symmetrical  displace- 
ment. 

The  principle  of  the  method  is  the  interaction  of 
forces,  the  one  fragment  serving  as  a  fulcrum  for  the 
mobilisation  of  the  other  and  vice  versa.  Where, 
however,  there  is  marked  discrepancy  in  the  size  of 

Fig.  52. — Apparatus  for 
expansion  of  the  mandible. 
(Each  lateral  fragment  is  en- 
closed in  a  splint  carefully 
cemented  to  the  teeth,  the 
base  of  which  descends  as  low- 
as  possible  along  the  entire 
length  of  the  lingual  surface. 
The  posterior  jack-screw  is 
placed  very  low,  approxi- 
mately in  the  region  of  the 
apex.  Its  two  extremities 
are  contained  in  two  cavities 
in  pigeon's- nest  form  on  the 
lingual  face  of  the  splints, 
where    they    are   secured   by 

means  of  a  pin.  A  second  extension  mechanism  acts  upon  tho 
anterior  extremities  of  the  fragments.  It  is  lixedas  close  as  possible 
to  the  occluding  surfaces  of  the  teeth.  It  consists  of  a  threaded  rod 
running  in  two  tubes  which  are  attached  to  the  anterior  extremities 
of  the  splints.  The  screw-rod  is  furnished  with  four  nuts  placed 
one  at  each  entry  and  one  at  each  exit  of  the  tubes.  By  manipu- 
lating these  screws,  expansion  and  immobilisation  may  be  effected 
at  the  same  time.) 

the  fragments,  the  smaller  inevitably  tends  to  become 
displaced. 

Where  greater  force  is  required  to  overcome  the 
mandibular  contraction,  the  mechanism  shown  in 
figs.  52  and  53  is  preferable.  Here  the  expansive 
force  is  conveyed  by  means  of  jack-screws. 

In  this  instance  the  stress  is  directly  transmitted 
to  the  mandibular  fragments,  owing  to  the  fact  that 


(>8G      FRACTURE  OF   THE  LOWER  JAW 


Figs.  53,  54,  and  53.— Extension  apparatus  for  use  in  mandibular 
contraction.  (This  apparatus  is  described  by  Dr.  Besson,  and 
possesses    the   following    characteristics— in    many    particulars  it 

closely  resembles  an  appa- 
ratus seen  by  us  at  Val- de- 
Grace,  where  it  was  em- 
ployed by  Dr.  Frey :  "It 
consists  of  two  metal  cap 
splints  struck  in  two  parts, 
articulated  at  the  back  by 
means  of  a  hinge  and  closed 
in  front  by  means  of  a  screw. 
The  two  splints  are  accur- 
ately applied  to  the  frag- 
ments, covering  the  lateral 
faces  of  the  teeth  and  the 
gingival  mucosa  as  far  down 
as  possible.  They  are  ce- 
mented to  the  teeth,  the  oc- 
cluding surfaces  of  which  are 
left  free.  Between  the  two 
splints  in  front  two  jack- 
screws  are  fixed,  one  above, 
the  other  below.  The  first  is 
placed  as  close  to  the  teeth 
as  jDossible.  The  second  is 
placed  as  low  down  as  possi- 
ble between  the  mesial  sur- 
faces of  the  same  teeth. 
Upon  the  lingual  surface  of 
the  splints,  as  low  down  as 
possible,  and  behind  the 
teeth  which  erupt  at  six 
j'ears,  attachments  are  fixed 
for  an  elastic  arch  of  piano 
wire  which  surrounds  the 
inferior  dental  arch.  The 
attachment  of  the  jack-screws  and  the 
vestibular  arch  is  effected  by  means  of 
knee-joints.  This  gives  an  extreme 
pliability  to  the  entire  mechanism.  It 
also  facilitates  the  individual  movement 
of  each  fragment  in  response  to  the 
forces  acting  upon  it."  The  extension 
apparatus  shown  in  fig.  52,  which  im- 
mobilises the  fragments  while  at  the 
same  time  holding  them  apart,  is  chiefly 
indicated  in  fracture  where  union  may 
be  anticipated,  and  which  are  better 
for  being  kept  immobilised  during  the  extension  period.  Besson's 
mechanism,  on  the  other  hand,  owing  to  its  extreme  pliabihty, 
is  more  suitable  for  employment  in  confirmed  pseudo-arthrosis.) 


MECHANICAL   TREATMENT 


f>,S7 


the  jack-screw  is  placed  very  low,  very  nearly  at  the 
point  of  union  of  the  alveolar  and  basilar  portions  of 
the  mandible. 

In  cases  where  it  is  not  possible  to  employ  the 
sub-lingual  jack-screw,  Duchange's  apparatus  is  indi- 
cated. Ingenious  appliances  with  extra-buccal  anchor- 
age have  been  introduced  by  Guerini  of  Naples. 


Fig.  5G. — Duchangcrs  aijparatus  for  the  correction  of  mandi- 
bular contraction.  (Each  of  the  two  fragments  is  fitted  \v\i\\  a 
cap  splint  (1,  1')  which  is  cemented  to  the  teeth;  anchorage  is 
reinforced  by  screws  (0)  penetrating  the  interdental  spaces.  Threaded 
rods  (3)  are  soldered  to  the  metal  cai)s.  The  free  ends  of  these 
rods  are  passed  throngh  eyelet  holes  arranged  at  intei-vals  in  a 
rigid  metal  arch  (2).  By  turning  the  nut  (.5)  and  the  counter-screw 
(4)  in  the  threaded  rod,  the  mandibular  fi'agnients  are  drawn  into 
the  required  position. 

When  the  mandibular  deformity  has  been  corrected, 
the  fragments  are  immobilised  by  either  retention 
mechanisms  or  by  the  double  splint  with  anchor- 
bands  shown  in  figs.  42  and  43. 

3.  Double  Fracture. — ^Similar  methods  are  em- 
ployed in  the  reduction  of  bilateral  fracture  with 
median  third  fragment.     Fig.  57  shows  such  a  fracture, 


688      FRACTUBE  OF  THE   LOWER  JAW 


and  the  instrument  for  its  reduction  is  shown  in  figs. 
42  and  43. 

Occasionally  the  median  fragment  shows  a  ten- 
dency to  downward  and  outward  displacement,  a 
condition  which  it  is  difficult  to  correct  by  means  of 
Angle's  alignment  wire.  In  cases  of  this  nature  inter- 
maxillary   anchorage    is    employed.     A    mechanism 

furnished  with  hooks  is 
attached  to  the  third 
fragment  by  means  of 
anchor-bands.  The 
hooks  are  connected, 
by  means  of  elastics 
with  a  siDiilar  device 
attached  to  the  an- 
terior teeth  of  the 
upper  jaw. 

Median  and  para- 
median fracture  is 
sometimes  complicated 
by  vertical  displace- 
ment of  the  fragments.  This  produces  an  irregu- 
larity in  the  horizontal  plane  which  must  be  cor- 
rected before  immobilisation.  This  is  best  done  by 
means  of  an  apparatus  similar  to  that  represented 
in  fig.  59.  It  is  composed  of  cap  splints  cemented 
to  the  lateral  fragments.  A  firm  anchorage  is 
essential,  and  this  is  assured  by  screws  at  the  inter- 
dental spaces.  A  spring  is  attached  to  the  lingual 
aspect,  the  action  of  which  is  slightly  to  separate  the 


Fig.  57. — Angle' a  arch  employed 
to  reduce  bilateral  fracture.  The 
jaw  is  the  same  as  that  shown  in 
figs.  42  and  43,  where  the  fracture 
is  reduced  and  immobilised  by  a 
double  splint  with  anchor  bands. 


MECHANICAL  TREATMENT 


689 


two  fragments  and  to  lower  the  elevated  fragment. 
Attached  to  the  labial  surfaces  are  two  pierced  metal 
projections.     When  reduction  is  complete  these  exactly 
face  one  another.     All 
that     remains     to    be 
done  is  to   immobilise 
the   fragments    by   in- 
troducing  a  U-shaped 
bolt  into  the  holes  in 
the    splint    previously 
occupied  by  the  spring, 
and  a  straight  threaded 
bolt     furnished     with 
nuts  into  the  holes  in 
the  metal  projections. 

Should  the  vertical 
displacement  not  yield 
to  this  method,  a 
mechanism  with  inter- 
maxillary anchorage, 
such  as  that  shown  in 
fig.  64,  should  be  em- 
ployed. 

In  this  case  elastic 
bands  are  stretched 
between    each    of    the 

fragments  and  the  upper  jaw.  Their  action  tends 
to  separate  the  fragments  and  to  draw  them  into 
contact  with  the  superior  dental  arch  until  normal 
occlusion,  that  is  to  say  reduction,  is  obtained. 


Fig,  68. — Method  of  intermaxil- 
lary anchorage  for  the  purpose  of 
bringing  a  median  fragment  dis- 
placed downwards  andforwards  into 
occlusion.  The  teeth  of  the  upper 
jaw  are  fitted  with  a  rigid  metal 
rod  to  which  hooks  are  attached. 
A  similar  device  is  attached  to  the 
teeth  of  the  loose  fragment.  Elastic 
bands  of  varying  number  are 
stretched  between  the  hooks  of  the 
two  arches,  thus  correcting  the 
deviation. 


G90      FRACTURE  OF   THE   LOWER  JAW 

It  was  in  cases  of  tliis  sort  that,  iu  former  days, 
CI.  and  Fr.  Martin  practised  their  "  open  mouth  ' 
treatment. 

We  have  frequently  been  struck  by  the  facility  with 
which  considerable  loss  of  substance  in  the  mental 
region    is    made    good.     The    characteristic    is    quite 


Fig.  59. — Apparatus  for  the  correction  of  vertical  deviation  in 
median  or  paramedian  fracture.  The  metal  splint  is  divided  at 
the  fracture  site.  Each  portion  is  cemented  to  the  teeth  and  is 
also  secured  by  means  of  screws  (1,  2,  1',  2')  between  the  interdental 
spaces.  A  spring  (3)  corrects  the  deviation.  When  the  reduction 
is  effected  the  fracture  is  inamobilised  by  means  of  bolts  which  fix 
the  two  splints  in  position. 


specific  and  is  not  observed  in  lateral  fracture.  It  may 
be  due  to  the  richer  vascularisation  of  the  mental 
region. 

B.  Posterior  Fracture. — Of  all  classes  of  fracture, 
this  is  the  one  most  liable  to  terminate  in  pseudo- 
arthrosis.    Every  effort  should  be  made  to  bring  the 


MECHANICAL   TREATMENT 


691 


fragments  into  apposition,  in  the  hope  of  effecting  a 
union. 

I.  Recent  Lateral  Fracture,  with  slight  or  medium 
loss  of  substance  (up  to  3  cm.). — ia)  Posterior  fragment 
containing  teeth  or  roots  suitable  for  purposes  of 
anchorage. 

When  the  loss  of  bony  substance  does  not  exceed 
li  cm.,   treatment  consists  in  immobilisation  of  the 


Fig.  60. — Lateral  fracture  with  large  loss  of  substance.  Spon- 
taneous union.  Compensatory  displacement  of  the"  posterior 
fragment. 

fragments  in  normal  occlusion  by  means  of  either  a 
double  splint  with  anchor  bands  or  a  bridge.  In  the 
case  of  the  latter  it  is  advisable  to  strengthen  the 
anchorage  of  the  supporting  crowns  by  screws  or 
bolts  penetrating  well  into  the  pulp-cavities  and 
canals,  the  latter  having  been  previously  enlarged. 

Where  the  loss  of  substance  is  greater  (up  to  about 
3  cm.),  simple  immobilisation  should  also  be  employed, 
provided  always  that  the  destruction  is  not  absolute, 


692      FRACTURE   OF   THE  LOWER  JAW 

and  that  splinters  are  present  in  the  fractured  area. 
Skiagrams  should  be  employed  for  the  determination 
of  these  factors.  It  is  permissible  to  count  upon  the 
vitality  of  these  bony  fragments  and  of  the  traces  of 
periosteum   by   which  they  are   accompanied,   which 


Fig,  61. — Same  case  as  fig.  60.     Skiagram  of  the  united  fracture. 


play  a  very  important  part  in  effecting  union.  The 
action  of  the  immobilisation  apparatus  should  be 
confined  to  maintaining  the  principal  fragment  in 
good  occlusion.  No  attempt  should  be  made  to  get 
the  posterior  fragment  into  occlusion  ;  it  has  already 
undergone  spontaneous  displacement  by  which  it  has 


MECHANICAL   TREATMENT  G93 

been  brought  closer  to  the  principal  fragment.  To 
interfere  with  this  displacement  is  to  endanger  union. 
Moreover,  is  there  ?ny  decided  advantage  attaching 
to  its  retraction  ?  There  is  no  very  great  incon- 
venience in  the  fact  that  the  last  inferior  molar  articu- 
lates with  the  second  superior  molar.     This  represents 


Fig.  62. — Same  case  with  prothetic  apparatus. 

a  very  slight  degree  of  malocclusion,  and  one  which 
is  easily  remedied  later. 

For  purposes  of  retention  bridges  or  sj^lints  should 
be  employed.  We  ourselves  prefer  the  apparatus 
shown  in  fig.  64,  which,  in  cases  of  this  class,  is 
used  solely  as  an  immobilisation  agent.  It  has  certain 
advantages  over  other  immobilisation  mechanisms. 
The  posterior  fragment  is  connected  with  the  splint 
attached  to  the  principal  fragment  by  a  double  sliding 
bar,  which  resists  mobility  in  the  transverse  and  the 
vertical  sense,  but  permits  the  spontaneous  forward 


694      FRACTURE  OF   THE  LOWER  JAW 

movement   of   the   posterior  fragment,    a   movement 
which  is  very  favourable  to  the  co-adaptation  of  the 


Fig.  63. — Photograph  of  the  patient  whose  fracture  is  repro- 
diiced  in.  the  preceding  illustrations.  The  fracture  united  spon- 
taneously, the  posterior  fragment  coming  forward.  Flattening  of 
the  angle  of  the  fractured  side. 

fragments  and  to  ultimate  union.    The  double  screw  is 

employed  solely  to  fix  displacement,  never  to  provoke  it. 

Where  the  bony  loss  is  1|  to  3  cm.  in  length  and  is 


MECHANICAL   TREATMENT  095 

shown  by  skiagrams  to  be  absolute,  especially  where 
it  includes  the  basilar  portion  of  the  bone,  distinct 
advantage  is  derived  from  bringing  the  posterior 
fragment  forward.  The  interval  between  the  frag- 
ments is  lessened  or  may  even  be  filled,  and  the 
chance  of  evading  ultimate  pseudo-arthrosis  is  in- 
creased. 

It  is  important  to  realise  that  this  compensatory 
forward  movement  by  mechanical  means  coincides  with 
a  natural  impulse  on  the  part  of  the  posterior  frag- 
ment which  may  be  counted  on  in  the  vast  majority 
of  lateral  fractures.  The  following  clinical  history  is 
interesting  in  this  connection. 

The  patient  was  wounded  in  Morocco  in  July  1914  ; 
his  mandible  was  fractured  but  united  well.  The 
fracture-site  is  bounded  by  the  left  lateral  incisor  on 
the  one  hand,  and  by  the  first  or  second  molar  on  the 
other.  Hence  the  amount  of  substance  lost  must 
equal  at  least  three  teeth.  Although  no  mechanical 
measures  were  employed,  perfect  union  with  formation 
of  callus  resulted.  There  is  a  slight  deviation  of  the 
mandible  towards  the  fractured  side ;  occlusion  is 
satisfactory. 

It  is  v/ith  the  object  of  obtaining  results  similar  to 
these  that  the  apparatus  shown  in  figs.  64  and  65  is 
designed.  By  a  system  of  sliding  rods  and  screws 
the  fractured  surfaces  are  drawn  together  and  the 
fragments  are  at  the  same  time  maintained  in 
rigorous  immobility  during  the  entire  period  of  treat- 
ment. 


696      FRACTURE  OF  THE  LOWER  JAW 


By  releasing  the  screw  the  apparatus  may  from  time 
to  time  be  sufficiently  loosened  to  permit  of  examina- 
tion of  the  site  of  fracture.     The  apparatus  is  easy 

of  construction  and 
of  application  ;  it  is 
clean  ;  and  it  is  very 
well  tolerated  by  the 
patient.  It  should 
be  applied  as  early 
as  possible,  and  dur- 
ing the  first  week  of 
its  application  the 
screws  should  be 
gradually  tightened 
until  the  fractured 
surfaces  meet.  The 
results  are  verified 
by  examination  of 
the  fracture  site  and 
by  skiagrams. 

The  action  of  the 
sliding  bars  is  sup- 
plemented by  inter- 
maxillary traction  by 
means  of  elastic 
bands,  whose  object 
is 


Fig.  64. — Mechanism  employed  to 
move  the  posterior  fragment  forward, 
intermaxillary  force  being  exercised  at 
the  same  time.  The  mechanism  con- 
sists of  a  threaded  rod,  one  end  of 
which  is  attached  to  a  crown  which 
covers  the  tooth  on  the  short  fragment, 
the  other  end  rulis  through  a  tube 
soldered  to  the  alignment  wire  on  the 
principal  fragment.  By  tightening  the 
screw  and  counter-screw  in  front  of 
the  tube  the  posterior  fragment  is 
drawn  forward.  On  the  lingual  side  a 
somewhat  similar  mechanism  is  pla^ced, 
but  this  is  not  furnished  with  screw 
and  counter-screw. 

it  is  to  prevent 
lateral  deviation  of  the  principal  fragment.  Both 
tractions  are  maintained  during  the  entire  period  of 
treatment.     Once  the  fragments  have  been  brought 


MECHANICAL   TREATMENT  G97 

together,  the  screws  of  the  sliding  bars  are  not  again 
released.* 

Fraction  of  the  posterior  fragment  does  not  demand 
a  very  resistant  anchor  point.     A  single  tooth  is  suffi- 
A 


Fig.  65. — Mechanism  to  bring  forward  and  to  immobilise  the 
posterior  fragment.  The  tooth  on  the  posterior  fragment  is  fitted 
with  a  band  A  attached  by  cement.  On  the  hngual  face  of  this 
band  a  German  silver  wire  B  is  soldered,  which  runs  through  the 
tube  G,  which  is  soldered  to  the  anchorage  D  attached  to  the 
principal  fragment.  ,The  mechanism  is  repeated  on  th.e  labial 
face  of  the  band  A,  with  this  difference,  that  the  extremity  of  the 
wire  running  through  the  tube  C"  is  threaded.  A  screw  E  and  a 
counter-screw  E'  are  fitted  to  the  threaded  end  of  the  wire  at  its 
exit  from  the  tube.  By  tightening  the  screw  E,  the  posterior  frag- 
ment is  drawn  forward,  while  at  the  same  time  an  absolute  immo- 
bility is  maintained. 

cient,  even  though  very  much  loosened  or  broken. 
The  anchor  appliance  itself,  however,  should  be  veiy 
strongly  attached.     Bands  are  not  sufficiently  resis- 

1  Instead  of  intermaxillary  anchorage  by  means  of  elastic  bands 
the  apparatus  described  later  under  the  name  of  "  active  crank  " 
may  be  employed.     The  method  yields  excellent  results. 


098      FRACTURE   OF   THE    LOWER  JAW 

tant ;  crowns  should  always  be  used,  and  it  is  fre- 
quently better  to  reinforce  them  by  screws  going  well 
down  into  the  pulp  cavity  and  the  distal  root  canal. 

This  mechanism  not  only  reduces  the  fracture,  but 
it  so  absolutely  immobilises  the  fragments  that  to 
employ  a  special  immobilisation  apparatus  is  un- 
necessary. 

It  is  a  remarkable  fact  that,  where  there  is  large 
loss  of  bony  substance,  the  deformity  of  the  mandibular 
arch  is  much  less  than  would  be  supposed.  This  is 
due  to  the  tendency  of  the  posterior  fragment  to  move 
forward  and  thus  to  occupy  the  place  of  the  missing 
bony  portion. 

Then  again,  the  establishment  of  occlusion  is  greatly 
aided  by  the  extreme  mobility  of  the  temporo-mandi- 
bular  joints.  These  movements  are  determined  and 
fixed  by  the  intermaxillary  traction  of  the  elastic 
bands,  and  This  traction  should  therefore  be  very 
judiciously  employed. 

By  this  method  we  have  in  some  cases  effected 
compensation  for  loss  of  bonj^  substance  corresponding 
to  two  molars  (about  2 J  cm.)  with  satisfactory  union 
of  the  fragments.  Owing  to  the  specific  adaptive 
quality  of  the  temporo-mandibular  joints,  in  no  case 
has  malocclusion  resulted.  Naturally,  the  results  are 
best  when    the  loss  of  substance  is  least. 

The  principle  of  the  method  may  at  first  sight  seem 
to  be  somewhat  daring,  but  it  is  justified  b}^  results. 
The  fact  that  occlusion  is  preserved  in  spite  of  the 
sliortening  of  the  body  of  the  mandible,  removes  the 


MECHANICAL   TREATMENT  099 

only  objection  to  the  method  wliich  might  have  been 
advanced. 

The  measures  employed  by  stomatologists  for  the 
correction  of  malocclusion  are  various.  Expansion  of 
the  mandible  is  a  common  orthodontological  procedure. 
Elongation  of  the  callus,  as  described  in  connection 
with  median  fracture,  may  also  be  employed  here,  and 
we  are  convinced  that  by  this  means  it  is  possible  to 
compensate  for  a  bony  loss  in  excess  of  3  cm. 

Recourse  to  instruments  of  prosthesis  is  necessitated 
by  the  nature  of  certain  cases.  Where  half  the  lower 
dental  arch  closes  inside  the  upper  arch,  thus  losing 
all  contact  with  the  corresponding  teeth  above  it, 
it  is  a  simple  measure  to  line  the  upper  arcade  with 
triturating  surfaces  in  such  a  way  that  they  articulate 
with  the  teeth  of  the  lower  jaw  (P.  Robin). 

A  mechanism  of  this  kind,  if  only  on  account  of  its 
method  of  equilibrium,  is  eminently  stable,  and  its 
efficacy  does  not  depend  upon  the  presence  of  the  teeth. 
Moreover  it  should  be  borne  in  mind  that  the  absorp- 
tion of  the  bone,  consequent  upon  the  loss  of  the  teeth, 
is  always  very  mti^h  more  marked  in  the  case  of  the 
maxilla  than  of  the  mandible.  This  physiological 
change  has  the  favourable  effect  of  restoring  to  a 
certain  extent  the  harmony  between  the  sound  upper  " 
jaw  and  the  contracted  lower  jaw. 

We  have  therefore  every  right  to  assert  that  the 
future  of  these  cases  is  as  assured  as  their  present. 
Where  there  is  pseudo-arthrosis,  on  the  other  hand, 
the  patient  must  sooner  or  later  become  disabled. 


700     FRACTURE  OF   THE  LOWER  JAW 


Occasionally  the  method  is  unsuccessful  and  union 
is  not  obtained.  But  even  in  cases  such  as  these 
the  treatment  has  certain  favourable  effects.  The 
forward  movement  of  the  posterior  i^ragment  permits 
the  employment  of  osteo-synthetic  measures  in  place 
of  the  bony  graft,  prognosis  in  the  case  of  the  latter 

method  being  far  less 
favourable  than  in 
the  case  of  the 
former. 

(6)  The  ^posterior 
fragment  offers  no 
anchorage  point.  — 
Where  the  posterior 
fragment  is  accessi- 
ble, it  should  be  en- 
closed in  a  cap  which 
descends  very  low, 
particularly  on  the 
lingual  side.  This 
cap  is  soldered  to  a 
double  splint  with 
anchor  bands, 
which  is  adjusted  and  cemented  to  the  larger  frag- 
ment. 

The  posterior  fragment  is  applied  to  the  cap  which 
covers  it  by  the  tonicity  and  the  contractions  of  the 
elevator  muscles,  a  satisfactory  immobilisation  being 
thus  obtained  (fig.  66). 

Where  the  mandible  shows  a  tendency  to  lateral 


Fig.  66. — Immobilisation  apparatus 
for  lateral  fracture.  There  is  no  an- 
chorage point  on  the  posterior  frag- 
ment. The  cap  which  encloses  the 
posterior  fragment  descends  very  low 
especially  on  the  lingual  side.  It  is 
soldered  to  a  double  splint  with  anchor 
bands  which  is  cemented  to  the  teeth 
of  the  principal  fragment.  This  con- 
stitutes an  efficient  method  of  anchor- 
age. 


MECHANICAL  TREATMENT  701 

deviation,  intermaxillary  anchorage  as  described  above 
should  be  employed. 

To  render  the  method  more  efficient,  the  posterior 
splint  may  be  attached  to  that  on  the  principal  frag- 
ment by  means  of  a  device  with  a  double  bolt,  which 
permits  of  the  posterior  splint  being  raised  for  pur- 
poses of  inspection  or  cleansing.  This  instrument  is 
described  in  detail  later. 

Where  the  loss  from  the  posterior  fragment  is  so 
extensive  that  immobilisation  is  not  possible,  the 
clinical  appearances  resemble  those  of  fracture  of  the 
an^lc,  and  the  therapeutic  indications  are  the  same. 

2.  Old  Lateral  Fracture  with  slight  or  medium  loss 
of  substance  (lJ-3  cm.). — Where  the  posterior  frag- 
ment presents  a  point  of  anchorage,  a  mechanism  should 
be  employed  to  bring  the  fragments  together.  We  have 
observed  the  union  of  lateral  fracture  with  large  loss 
of  substance  in  cases  where  treatment  had  not  been 
instituted  until  four  months  after  the  date  of  injury. 

In  all  cases,  including  those  in  which  union  is  not 
obtained,  the  bringing  together  of  the  fragments  greatly 
facilitates  surgical  intervention.  It  frequently  permits 
of  the  substitution  of  osteo-synthetic  methods,  which 
may  be  regarded  as  constant,  for  that  of  the  bony 
graft,  the  results  of  which  are  always  uncertain  (see 
chapter  on  Surgical  Treatment). 

Where  the  posterior  fragment  is  deprived  of  teeth  and, 
as  is  usually  the  case,  is  displaced  forwards  and  up- 
wards, the  first  care  should  be  to  get  it  into  normal 
position.     This  is  effected  either  by  a  mechanism  in 


702      FRACTURE  OF   THE  LOWER  JAW 

which  the  force  is  passive  and  resides  in  a  spring,  or 
by  means  of  the  app.'iratus  shown  in  fig.  67.  In  the 
latter  the  action  of  the  spring  is  supplemented  by 
intermittent  pressure  from  a  jointed  crank,  which  is 
brought  to  bear  upon  the  posterior  fragment  each 
time   that   the   elevator   muscles   contract   or   under 


Fig.  67. — Apparatus  for 
the  reduction  of  the  posterior 
fragment  when  it  is  displaced 
upwards  and  forwards  (G. 
Villain).  The  posterior  frag- 
ment is  enclosed  in  a  splint 
the  internal  face  of  which 
descends  very  low  along  the 
whole  lingual  face  of  the  frag- 
ment. This  splint  is  kept  in 
position  by  a  spring  of  low 
power  on  the  lingual  side. 
When  by  the  action  of  the 
elevator  muscles  the  jaws  are 
brought  together,  the  lower 
arm  of  the  crank  comes  to 
rest  in  a  groove  on  the  vesti- 
bular surface  of  the  splint. 
The  rod  of  the  crank  is 
threaded  and  fitted  with  a 
screw,  by  means  of  which  the 
action  of  the  crank  may  be 
regulated  according  to  need. 


the  simple  influence  of  their  tonicity.  The  apparatus 
is  designed  by  G.  Villain. 

When  reduction  has  been  obtained,  union  between 
the  posterior  and  anterior  splints  is  established  by 
uniting  them  with  solder  and  with  bolts,  as  shown  in 
fig.  66. 

Where  the  posterior  fragment  is  inaccessible,  the 
fracture  is  treated  on  the  lines  of  fracture  of  the  angle. 

3.  Old    Lateral  Fracture   with  Extensive  Loss  of  Sub- 


MECHANICAL  TREATMENT  703 

stance  (over  3  cm.). — (a)  Recent  fracture.  Where  the 
posterior  fragment  possesses  a  tooth  or  a  root  suitable 
for  an  anchorage  point,  the  fragments  are  first  trained 
into  a  position  of  normal  occlusion  and  then  im- 
mobilised. By  these  measures  both  the  deviation  of 
the  fragment  and  cicatricial  retraction  are  avoided  and 
subsequent  prosthetic  treatment  is  facilitated.  The 
anchorage  upon  the  posterior  fragment  should  be  carried 
out  with  extreme  care.  The  best  method  is  by  a  screw- 
or  a  stud-crown. 

Where  the  posterior  fragment  is  toothless,  immo- 
bilisation in  occlusion  is  advised. 

{b)  Old  fracture. — Where,  as  so  frequently  happens, 
these  fractures  have  not  been  previously  immobilised, 
they  should  be  treated  in  the  same  way  as  recent 
fracture.  Until  such  treatment  has  been  vigorously 
pursued  for  at  least  three  mouths,  pseudo-arthrosis 
cannot  be  considered  definitive  and  should  not  be 
treated  as  such. 

C.  Fracture  of  the  Angle.— The  possibility  of  influ- 
encing the  posterior  fragment  is  here  very  limited. 
The  principal  fragment,  on  the  other  hand,  is  readily 
immobilised  by  attachment  to  the  upper  jaw.  This 
measure  prevents  any  movement  of  the  fracture-site 
which,  apart  from  loss  of  substance,  is  one  of  the 
chief  causes  of  pseudo-arthrosis  at  the  angle  and  is 
a  far  more  powerful  factor  than  muscular  or  tendinous 
intervention  (figs,  69  and  70). 

Once  again  we  emphasise  the  fact  that  immobilisa- 
tion in  occlusion  has  always  been  very  well  tolerated 


704     FRACTURE  OF   THE  LOWER  JAW 


^j>. 


PQ 


by  our  patients.    We  have  never  observed  infective 
phenomena  such  as  those  formerly  described  under 
the  name  of  buccal  cachexia.    This 
may  be  due  to  the  fact  that  the 
instrument  permits   of   scrupulous 
cleanliness.      Moreover,   we    have 
never    found    nutrition     seriously 
affected.     A  liquid  or  semi-liquid 
diet  is  given  which,  after  a  little 
practice,  is  readily  taken.    About 
every  fourteen  days  the  ligatures 
are  removed  and  the  fracture  site 
and  the  movements  of  the  temporo- 
mandibular   joints    are    carefully 
examined.     This    opportunity  for 
minute    cleansing    of    the    buccal 
cavity  is  not  neglected.      Closure 
of    the  jaws  has  never   been   ob- 
served, not   even   in   cases   which 
had  been  immobilised  for  several 
months.     The  most  we  have  ever 
seen  has   been   a   slight    articular 
stiffness  which   disappeared    after 
a  few  days  of  normal  function. 
To  avoid  immobilisation  in  oc- 
FiG.  68.    elusion  a  form  of  retention  appar- 
atus has  been  suggested  by  certain 
authors.      This  consists  of  a  prin- 
cipal splint  firmly  anchored  to  the  teeth,  to  which  a 
posterior  splint  is  attached  by  means  of  bolts.     The 


MECHANICAL  TREATMENT  705 

posterior  splint  encloses  the  ramus  and  is  fitted  to 
it  as  exactly  as  possible.  This  apparatus  is  shown 
in  fig.  71. 

The  construction  of  an  apparatus  of  this  nature  is 
always  a  delicate  matter,  and  it  is  especially  so  where 
the  jaws  are  constricted.     Moreover,  the  immobilisa- 


FiGS.  69  and  70. ^Apparatus  for  immobilising  the  jaws  in  occlu- 
sion. Metal  wires  with  spurs  are  attached  to  the  two  arches. 
They  are  anchored  by  at  least  four  bands,  A,  B,  C,  D,  which  are 
adjusted  and  cemented,  and  by  ligatures  of  brass  wire  by  which 
all  the  teeth  are  attached  to  the  anterior  arch.  At  intei-vals  of 
about  two  teeth,  spurs  {E,  F)  are  soldered  to  the  two  alignment 
wires.  By  means  of  ligatures  of  brass  wire  in  figure  of  eight,  the 
spurs  are  united  and  absolute  immobility  is  obtained. 

tion  of  the  posterior  fragment  by  this  method  appears 
to  us  very  precarious.  As  a  matter  of  fact,  the  posterior 
splint  can  enclose  only  the  anterior  border  and  a 
portion  of  the  lingual  surface  of  the  ramus.  In  our 
opinion  there  is  nO  guarantee  that  immobilisation  is 
effected.     The  apparatus  may  perhaps  be  indicated  in 


706     FRACTURE  OF  THE  LOWER  JAW 

angular  fracture  with  slight  loss  of  substance,  though 
these  fractures  frequently  unite  without  mechanical 
help.  But  its  use  in  fracture  with  large  loss  of  sub- 
stance is  utterly  condemned,  particularly  as  an  appara- 
tus of  this  kind  has  the  supreme  drawback  of  opposing 
the  natural  compensatory  forward  movement  of  the 
ramus,  a  movement  which  is  so  entirely  favourable 


Fig.  71. — Mechanism  for  the  iinmobihsation  of  the  posterior 
fragment  in  fracture  of  the  angle  with  slight  loss  of  substance.  The 
splint  which  covers  the  posterior  fragment  (ramus)  is  carried  as 
high  as  possible  up  the  anterior,  border  of  the  ramus,  and  descends 
as  low  as  possible  along  its  lingual  face.  It  is  attached  to  the 
principal  splint  by  a  dove-tail  joint  and  bolts.  It  is  removable,  thus 
facilitating  inspection  of  the  fracture  site  and  cleanliness. 


to  the  co-adaptation  of  the  fragments  and,  in  conse- 
quence, to  the  formation  of  the  callus. 

D.  Fracture  of  the  RamUs. — Simple  fractures  with- 
out displacement  frequently  unite  spontaneously.  We 
have  seen  a  large  number  of  cases  in  which  masticatory 
movement  had  been  restored  without  therapeutic 
intervention.  The  course  of  the  projectile,  however, 
showed  conclusively  that  fracture  of  the  ramus  had 


MECHANICAL  TREATMENT  707 

indeed  taken  place.  In  cases  of  simple  fracture  with- 
out displacement  we  confine  ourselves  to  a  "  watching 
treatment."  The  patients  are  closely  watched; 
modifications  in  the  articulation  of  the  teeth  are 
especially  looked  out  for  ;  and  measures  are  adopted 
to  guard  against  closure  of  the  jaws.  For  the  latter 
purpose  we  advise,  wherever  necessary,  mechanico 
therapeutic  dilatation  as  employed  in  the  treatment  of 
myotonic  constriction.  During  the  intervening  periods 
the  jaws  should  be  kept  apart  by  a  wooden  wedge 
inserted  between  the  dental  arches. 

Fracture  with  displacement  demands  a  twofold  treat- 
ment :  to  correct  the  deformity  of  the  mandible  and 
consequent  deviation  of  the  dental  arches  ;  and,  by 
immobilisation  of  the  jaws,  to  maintain  this  correction. 
Further,  rigidity  must  be  excluded. 

These  objects  are  best  obtained  by  the  method 
shown  in  fig.  72. 

Both  the  upper  and  lower  dental  arches  are  fitted 
with  alignment  wires  of  the  kind  employed  to  obtain 
immobilisation  in  occlusion.  Between  the  last  molars 
of  the  fractured  side  a  wedge  is  introduced  which  serves 
to  keep  the  jaws  about  2  cm.  apart.  The  jaws  are 
united  by  ligaturing  the  two  alignment  wires  together. 
On  the  sound  side  elastic  bands  are  stretched,  the 
number  of  which  varies  according  to  the  amount  of 
force  which  it  is  desired  to  employ.  This  mechanism 
recalls  the  "  open-mouth  "  attitude  recommended  by 
Claude  Martin  in  fracture  with  vertical  discrepancy 
of  the  fragments. 


708      FRACTURE  OF  THE  LOWER  JAW 

The  technique  of  this  apparatus  is  very  simple. 
The  wedge  of  wood  introduced  between  the  molars 
is  the  fulcrum  upon  which  the  entire  body  of  the 
mandible  moves.  Movement  is  induced  by  the  elastics 
stretched  between  the  jaws  on  the  sound  side,  and  is 
continued  until  the  space  between  the  dental  arches 
is  eliminated. 


Fig.  72. — Mechanism  for  reduction  of  fracture  of  the  ramus  with 
displacement.  Immobilisation  of  the  right  side  is  effected  by  means 
of  simple  ligatures,  a  wedge  of  wood  being  inserted  between  the 
last  molars.  On  the  left  side,  similar  ligatures  are  reinforced  by 
elastics,  the  action  of  which  tends  to  counteract  the  gap  between 
the  teeth  in  occlusion. 

Immobilisation  with  the  open  mouth  has  the  further 
advantage  of  effectually  counteracting  osteo-fibrous 
constriction. 

It  may  possibly  be  objected  that  the  movement  of 
the  mandible  might  have  the  effect  of  shifting  one 
or  other  of  the  fractured  surfaces  and  thus  imperilling 
union. 

The  answer  to  this  objection  lies  in  the  fact  that 


MECHANICAL  TREATMENT  70D 

the  process  of  prolongation,  to  which  the  callus  is 
subjected  during  formation,  is  modified  in  such  a  way 
that  slight  resistance  only  is  offered  to  the  co-adapta- 
tion of  the  fragments.  Moreover,  pseudo-arthrosis 
is  a  far  less  frequent  complication  here  than  in  cases 
where  the  fracture  is  situated  at  the  level  of  the 
horizontal  branch.  In  the  latter  case  the  fracture 
of  the  lever  results  in  almost  absolute  functional  in- 
capacity. 

Pseudo-arthrosis  of  the  ramus,  excluding  total  or 
partial  destruction  of  the  bone,  is  perfectly  compatible 
with  function.  As  an  instance,  the  case  of  a  man 
who  had  lost  an  entire  condyle  with  its  neck  and  who 
was  perfectly  able  to  masticate  his  food,  may  be  quoted. 
He  was  able  to  resume  his  military  service. 

The  apparatus  shown  in  fig.  72  seems  to  us  to  be 
the  method  par  excellence  of  dealing  with  these  cases, 
for  it  serves  to  reduce  the  fracture  while  at  the  same 
time  immobilising  the  fracture  site.  We  must  in 
fairness,  however,  record  the  results  obtained  with  the 
cranked  mechanism  (figs.  75  and  76),  of  which  a 
detailed  description  will  be  given  later.  This  mechan- 
ism is  at  first  employed  to  reduce  the  fracture  ;  later, 
by  blocking  the  screws  of  the  crank-head  it  is  used  as 
retention  apparatus. 

Fracture  of  the  condyle  with  loss  of  substance, 
whether  complicated  or  not  by  destructive  lesion  of 
the  glenoid  cavity,  presents  a  symptom-complex 
identical  with  that  associated  with  fracture  of  the 
ramus,  and  is  amenable  to  similar  treatment. 


710     FRACTURE  OF   THE  LOWER  JAW 

We  ourselves  have  never  seen  a  case  of  fracture  of 
both  rami  with  displacement  of  fragments,  but  it  is 
logical  to  assume  that  the  characteristic  attitude  of 
such  a  fracture  would  consist  in  a  bilateral  interval 
between  the  upper  and  lower  teeth.  Treatment  would 
consist  in  a  suitable  modification  of  the  method  just 
described. 


IV.     Tbeatment  of  Pseudo-arthrosis 

Fracture  presents  classical  pseudo-arthrosis  when 
union  has  not  been  effected  by  prosthetic  treatment  of 
at  least  six  months'  duration.  The  restorative  mechan- 
isms which  we  are  about  to  describe  are  designed  solely 
to  meet  the  requirements  of  such  cases.  But,  as 
G.  Villain  has  pointed  out,  this  mechanical  treatment 
must  be  regarded  as  a  step  only  in  the  general  manage- 
ment of  pseudo-arthrosis.  The  condition  is  amenable 
to  surgical  treatment,  to  which  there  is  a  growing 
tendency  to  refer  it. 

Pseudo-arthrosis  is  a  frequent,  though  not  a  fatal, 
accompaniment  of  fractures  complicated  by  large  loss 
of  bony  substance.  As  we  have  shown,  a  loss  of  sub- 
stance up  to  3  cm.  cannot  under  suitable  treatment 
be  regarded  as  a  bar  to  union. 

In  this  chapter  we  propose  to  deal  with  pseudo- 
arthroses due  to  very  large  loss  of  substance  (over 
3  cm.).  These  are  very  varied  in  character,  but  they 
may  be  classed  under  five  principal  headings  : 

I.  Median  pseudo-arthrosis. 


MECHANICAL   TREATMENT  711 

2.  Pseudo-arthrosis  of  the  body,  with  posterior 
fragment  suitable  for  purposes  of  anchorage. 

3.  Pseudo-arthrosis  of  the  body,  with  no  posterior 
fragment  or  one  useless  for  mechanical  purposes. 

4.  Pseudo-arthrosis  of  the  ramus,  with  loss  of  sub- 
stance at  the  temporo-mandibular  joint. 

5.  Extreme  cases,  with  loss  of  substance  corre- 
sponding to  the  entire  body  of  the  mandible  with  all 
its  teeth.  These  are  cases  where  the  comminution 
is  extreme  and  which  are  outside  classification. 

All  these  classes  of  lesion  are  accompanied  by  static 
and  dynamic  modifications,  by  which  function  is  very 
much  disturbed  or  even  destroyed. 

In  median  and  paramedian  pseudo-arthrosis  the 
fragments  are  equal  or  approximately  so,  and  are 
separated  by  a  considerable  interval.  They  tend  to 
approach  the  median  line  in  such  a  way  that  the  teeth 
lose  all  contact  with  the  corresponding  teeth  above 
them.  The  free  extremity  of  each  fragment  has  lost 
all  elevator  power  and  to  so  marked  an  extent  that, 
ev^n  where  dental  occlusion  is  re-established,  masti- 
catory movements  are  accompanied  by  the  mechanical 
depression  of  the  fragment.  Hence  the  derangement 
of  function  is  considerable  ;  it  is  no  exaggeration  to 
say  that  it  is  diminished  in  the  proportion  of  50  per 
cent. 

Very  similar  conditions  prevail  in  the  case  of  lateral 
pseudo-arthrosis.  The  principal  fragment,  being 
markedly  displaced  to  the  fractured  side,  is  useless 
for  mastication,  while  the  posterior  fragment,  being 


712     FRACTURE  OF  THE    LOWER  JAW 


Figs.  73  and  74.— 
An  apparatus  for  use  in 
median  pseudo-arthro- 
sis,  the  lateral  frag- 
ments possessing  teeth. 
The  teeth  are  covered 
by  cylindrical  crowns, 
attached  to  them  by 
cement  and  united  to 
one  another  in  such  a 
way  as  to  form  two 
solid  anchorage  blocks. 
These  anchor  blocks 
are  carefully  adjusted 
and  are  then  enclosed 
very  exactly  in  two 
telescopic  gutters.  The 
latter  depend  largely 
for  their  support  upon 
the  lingual  face  of  the 
bone,  where  they  are 
prolonged  as  far  as 
possible  both  back- 
wards and  downwards. 
They  are  united  by  a 
rigid  median  base  of 
great  resistancy,  upon 
which  the  prosthetic 
instrument,  which  is 
intended  to  fill  the  gap 
left  by  the  substance 
and  teeth  lost,  is  fixed. 
In  our  view  this  me- 
chanism is  infinitely 
the  best  for  the  treat- 
ment of  this  class  of 
case.  Its  stability  is  greater  than  that  of  simple  removable  appara- 
tuses. On  the  other  hand,  it  does  not  shorten  the  life  of  the  teeth 
as  does  the  bridj.e.  Its  anchorage  is  comparatively  free,  and  the 
strain  to  which  it  is  subjected  is  distributed  over  a  large  area  of 
the  mandible. 


displaced  either  inwards  or  outwards,  is  in  no  better 
condition. 

Pseudo-arthrosis  of  tlie  ramus  iias  a  somewhat 
better  prognosis,  the  reason  for  which  will  appear  later. 

The   greater   number   of   the   mechanisms  for  the 


MECHANICAL  TREATMENT  713 

treatment  of  these  conditions  are  dependent  for  their 
application  upon  the  presence  of  a  certain  number  of 
teeth.  Where  there  are  no  teeth,  the  infirmity  is 
almost  irremediable.  For  this  reason  mechanisms 
should  be  chosen,  the  .  anchorage  of  which  excludes 
traumatic  conditions  such  as  must  inevitably  hasten 
the  loss  of  the  teeth. 

Median  Pseudo-arthrosis. — A  mechanism  intended 
to  remedy  median  pseudo-arthrosis  should  fulfil' two 
requirements  :  it  should  maintain  the  lateral  frag- 
ments in  occlusion,  and  it  should  derive  from  them  a 
support  sufficient  to  assure  the  stability  of  the  replace- 
ment mechanism. 

The  first  qualification  is  fulfilled  by  mechanisms 
constructed  on  a  model  presenting  normal  occlusion. 
We  assume  that  the  fragments  have  undergone  pre- 
liminary orthognathic  treatment,  and  that  they  may 
be  readily  got  into  positions  of  normal  occlusion. 

The  question  of  anchorage  is  a  debatable  one.  Some 
authors  connect  the  two  fragments  by  means  of  a 
bridge,  strongly  cemented  to  the  teeth  by  means  of 
crowns,  which  are  soldered  together.  Others  prefer 
to  cap  the  teeth  of  each  fragment  and  then  strongly 
to  unite  the  caps,  thus  creating  two  resistant  anchor 
blocks,  to  which  a  removable  median  piece  is  attached 
by  various  methods. 

At  first  sight  the  bridge  appears  the  better  method 
of  the  two,  for  it  effects  perfect  immobilisation  while 
at  the  same  time  conveying  the  subjective  impression 
of    restored    function.     Experience    shows,    however, 


714     FRACTURE  OF  THE  LOWER  JAW 

that  the  abnormal  mobility  of  the  fragments  leads  to 
increased  activity  of  the  alveolo- dental  articulations, 
which  inevitably  terminates  in  the  loss  of  the  teeth. 

For  this  reason  we  prefer  a  removable  mechanism  or, 
better  still,  a  mechanism  part  of  which  is  fixed  and  part 
of  which  is  removable.  By  this  means  the  strain  upon 
the  dental  supports  is  reduced  to  a  minimum.  The 
most  effective  apparatus  is  that  shown  in  figs.  73  and 
74.  The  method  of  anchorage  is  entirely  satisfactory. 
Further,  owing  to  the  fact  that  its  internal  margin 
descends  very  low  on  the  lingual  side,  the  base  of 
support  is  broadened  and  the  natural  movement  of 
lingual  deviation  of  the  fragments  is  utilised  as  the 
method  of  fixation. 

Where  one  fragment  is  toothless,  the  results  of 
mechanical  treatment  are  obviously  more  precarious. 
In  such  cases  the  defective  anchorage  may  be  assisted 
by  broadening  the  base  of  support  and  by  employing 
an  intermaxillary  spring  such  as  that  shown  in  fig.  38. 

Where  both  fragments  are  toothless,  the  base  of  the 
plate  should  enclose  the  fragments  very  exactly  and 
should  extend  as  far  back  as  possible  upon  the  lingual 
side.  The  springs  may  be  strengthened  by  a  frag- 
ment of  piano- wire  slipped  into  the  lumen.  They 
should  be  placed  with  their  convexity  forward. 

Lateral  Pseudo-arthrosis. — ^Where  the  posterior  frag- 
ment bears  one  or  more  teeth,  there  is  always  the  temp- 
tation to  effect  connection  with  the  principal  fragment 
by  means  of  a  fixed  bridge.  This  method  may  be  em- 
ployed with  advantage  where  temporary  immobilisa- 


MECHANICAL   TREATMENT  715 

tion  is  required  with  a  view  to  obtaining  union.  But 
in  lateral  pseudo-arthrosis,  where  the  mechanism 
employed  should  have  the  character  of  a  definitive 
restorative  measure,  it  is  not  advisable. 

The  posterior  pillars  of  a  fixed  bridge  are  unlikely  to 
resist  for  long  the  very  considerable  strain  which  is  put 
upon  them  during  mastication.  Hence  it  is  advisable 
in  cases  of  this  sort  to  have  recourse  to  a  type  of 
mechanism  which  is  partly  fixed  and  party  removable. 
The  apparatus  should  be  designed  upon  lines  similar 
to  that  shown  in  fig.  73.  The  posterior  fragment  is 
very  exactly  covered  by  a  splint  which  covers  not 
only  the  teeth,  but  also  the  lingual  face  of  what  remains 
of  the  body,  angle,  and  ramus.  G.  Villain  advises  the 
incision  of  the  vestibular  cul-de-sac  in  the  retro-molar 
region,  performed  in  such  a  way  that  a  cul-de-sac  is 
formed  on  the  external  surface  of  the  angular  region 
of  the  mandible.  A  prolongation  of  the  base  of  the 
plate  is  slipped  into  this  cul-de-sac,  which  gives  an 
excellent  support.  By  this  means  a  very  large  area  of 
support  is  obtained.  The  sound  teeth  of  the  princi- 
pal fragment  should  be  treated  similarly  to  those  of 
the  lateral  fragment  (fig.  73). 

The  stability  of  a  mechanism  on  these  lines  is  usually 
entirely  satisfactory.  It  may,  however,  be  reinforced 
by  pins  inserted  at  intervals  in  the  dental  spaces, 
or  by  supplementary  hooks  which  hold  the  teeth 
together. 

Lateral  Pseudo-arthrosis,  with  total  loss  of  the  Posterior 
Fragment  or  its  disability  for  mechanical  purposes.— The 


71G     FRACTURE  OF  THE  LOWER  JAW 


Figs.  76  and  76. — Active 
and  passive  cranks. 

Fig.  75. — Passive  crank 
for  use  in  lateral  pseudo- 
arthrosis, the  posterior  frag- 
ment being  absent  or  use- 
less for  prosthetic  purposes. 
The  four  last  teeth  of  the 
right  maxilla  are  covered 
by  a  cast  silver  cap  splint 
which  is  firmly  cemented 
to  them.  To  the  posterior 
portion  of  this  splint  on 
the  labial  side,  the  cylinder 
of  the  crank  is  attached. 
The  attachment  is  by  means 
of  a  joint  permitting  move- 
ments of  circumduction. 
All  the  teeth  of  the  man- 
dibular fragment  are  en- 
closed in  an  open  cap  splint 
to  the  extremity  of  which, 
corresponding  with  the  site 
of  pseudo  -  arthrosis,  the 
piston  rod  of  the  crank  is 
attached.  This  crank-head 
is  able  to  perforrix  move- 
ments of  circumduction 
identical  with  those  of  the 
crank- head  on  the  upper 
splint.  As  the  jaws  are 
closed,  the  rod  telescopes 
nto  the  tube.  Its  length 
is  calculated  in  such  a  way  that  the  end  of  the  rod  reaches  the 
bottom  of  the  tube  at  the  moment  when  the  jaws  are  in  occlusion. 

Fig.  76. — Active  crank.  This  crank  differs  from  the  one  shown 
in  fig.  75  in  the  fact  that  its  rod  is  threaded  and  is  furnished  with 
a  screw  which,  in  movements  of  occlusion,  touches  the  orifice  of  the 
tube.  By  altering  the  position  of  the  screw,  the  crank  may  be 
brought  into  action  before  the  end  of  the  rod  reaches  the  bottom 
of  the  cylinder.  By  this  means  it  is  possible  to  determine  empiri- 
cally the  length  which  the  rod  should  have  in  order  to  produce 
a  given  effect.  A  passive  crank  may  then  be  constructed  which 
will  present  the  maximum  of  efficiency. 

therapeutic    problems   presented  by  pseudo-arthrosis 
of  this  nature  are  very  complex. 

In  each  of  the  preceding  classes  of  case  it  has  been 
possible  to  re-establish  a  certain  solidarity  between 


MECHANICAL  TREATMENT  717 

the  fragments,  and  by  this  means  to  obtain  a  sufficiently 
satisfactory  mandibular  function.  Here,  on  the  other 
hand,  we  are  faced  with  a  single  fragment,  which  has 
lost  all  connection  with  one  temporo-mandibular  articu- 
lation, and  which,  in  consequence,  possesses  an  irreduc- 
ible tendency  to  lateral  deviation,  thus  losing  all 
functional  ability. 

It  has  been  held  by  some  that  an  apparatus  main- 
taining the ,  normal  occlusion  of  the  teeth  during 
functional  activity  would  meet  the  requirements  of 
the  case.  Other  authors  have  believed  that  such  a 
therapy  represented  the  minimum  of  treatment,  and 
have  sought  to  remedy  the  fracture  of  the  mandibular 
lever,  either  by  the  creation  of  an  artificial  temporo- 
mandibular joint  to  which  the  free  end  of  the  frag- 
ment is  connected,  or,  by  transmitting  to  the  fractured 
extremity  sufficient  elevator  force  (flexible  cables)  for 
the  performance  of  movements  of  mastication,  equal  to 
those  performed  by  the  rest  of  the  mandibular  fragment. 

Up  to  now  sufficient  evidence  in  regard  to  the  latter 
method  has  not  been  forthcoming.  There  is,  however, 
a  well-proved  method  of  reduction  in  these  cases 
which  has  been  described  by  G.  Villain,'  who  calls  it 
a  "  crank." 

The  crank  is  an  apparatus  which  depends  on  inter- 
maxillary force.  It  is  anchored  to  the  fixed  bony 
mass  of  the  upper  jaw,  and  reacts  upon  the  mandible 
or  one  of  its  fragments  (figs.  75  and  76). 

1  G.   Villain,    "  Traitement  physiologique   des  fractures   et   des 
luxations  de  la  machoire,"  Odontologie,  August  30th,  1916. 


718     FRACTURE  OF   THE  LOWER  JAW 

The  mechanism  consists  of  a  rod  which  telescopes 
into  a  tube.  Rod  and  tube  are  attached  by  means 
of  removable  splints,  the  tube  to  the  upper  jaw,  the 
rod  to  the  lower,  or  inversely  according  to  the  require- 
ments of  the  case.  The  heads  of  the  crank  are 
attached  to  the  splints  by  joints,  which  permit  of 
movements  of  circumduction  upon  the  attachment 
screws,  in  such  a  way  that  elevator  and  depressor 
movements  are  not  interfered  with.  If  a  little  play 
is  allowed  to  the  heads  of  the  crank,  movements  of 
circumduction  may  also  be  performed. 

The  mechanism  of  the  apparatus  is  best  understood 
by  studying  its  action  in  a  given  case. 

The  mandibular  fragment  bears  a  splint,  to  the  free 
end  of  which  the  rod  of  the  crank  is  attached.  The 
tube  is  attached  either  to  a  fixed  splint  or  to  a  remov- 
able apparatus  upon  the  maxilla. 

During  depression  of  the  mandible  there  is  a  ten- 
dency on  the  part  of  the  fragment  to  lateral  deviation, 
but  this  is  possible  only  within  the  very  narrow  limits 
permitted  by  the  laxity  of  the  crank  heads.  When 
the  jaw  is  elevated,  the  rod  plunges  into  the  tube, 
and  the  length  of  the  rod  is  so  calculated  that  its 
extremity  touches  the  bottom  of  the  tube  at  the 
moment  when  the  jaws  are  in  occlusion.  The  effect 
is  to  force  the  teeth  of  the  lower  jaw  into  occlusion, 
and  to  maintain  them  in  that  position. 

This  is  the  passive  crank  employed  for  the  reduction 
of  deviations  which  are  readily  amenable  to  treatment. 
Where  correction  of  the  deviation  is  more  difficult,  the 


MECHANICAL   TREATMENT  719 

active  crank  is  preferable.  This  differs  from  the  passive 
crank  only  in  the  fact  that  the  rod  is  threaded  and 
furnished  with  a  nut.  By  screwing  the  nut  towards 
the  orifice  of  the  tube  the  latter  is  arrested  before  the 
position  of  occlusion  is  reached.  Thus,  at  eafch  eleva- 
tion of  the  mandible  a  degree  of  pressure,  which  varies 
in  accordance  with  the  position  of  the  screw,  is  exer- 
cised, the  effect  of  which  is  to  propel  the  mandibular 
fragment  into  good  position. 

As  soon  as  the  displacement  becomes  amenable 
the  threaded  rod  is  replaced  by  a  smooth  one. 

In  certain  special  cases  it  is  necessary  to  increase 
the  length  of  the  piston  stroke,  and  for  this  purpose 
the  elbow-crank  (fig.  77),  the  jointed  crank  (fig.  78), 
the  crank  with  horizontal  attachments  (fig.  79),  are  all 
employed.  Where  it  is  desired  to  modify  the  centre  of 
rotation,  the  crank  is  mounted  on  vertical  prolongations. 

The  crank  is  usually  well  tolerated  and  its  thera- 
peutic value  is  incontestable.  It  appears  to  act  as 
something  more  than  a  simple  guide  ;  the  connection 
thus  established  between  the  jaws  on  the  fractured 
side  serves  as  a  kind  of  support  to  the  free  extremity 
of  the  mandibular  fracture. 

The  action  of  the  crank  is  intermittent  and  is  exer- 
cised only  at  the  moment  of  muscular  activity.  In 
such  cases  as  the  one  under  discussion,  the  crank 
is  infinitely  superior  to  the  old  method  of  guides  or 
of  intermaxillary  elastics. 

Such  is  the  apparatus  usually  employed  to  remedy 
this  grave  form  of  pseudo-arthrosis. 


720      FRACTURE  OF   THE   LOWER  JAW 

The  apparatus  reproduced  in  fig.  81  was  designed 
by  M.  Bosano,  a  surgeon  dentist  and  one  of  our  clinical 
assistants.  In  our  view  it  represents  a  very  happy 
modification  of  the  crank.  It  is,  in  fact,  a  jointed 
crank,  the  cylinder  being  replaced  by  a  metal  splint 
the  upper  surface  of  which  is  furnished  with  articu- 
lations which  interdigitate  with  the  teeth  of  the  upper 


Fig.   77. — Elbow  crank. 

Fig.   78. — Jointed  crank. 

Fig.  79. — Crank  mounted  on  horizontal  prolongations. 

Fig.  80. — Crank  mounted  on  vertical  prolongations. 

jaw.  This  arrangement  possesses  all  the  advantages 
of  the  crank  while  at  the  same  time  re-establishing 
mastication  upon  the  fractured  side. 

Among  other  apparatuses  designed  to  the  same 
end  some,  of  which  one  is  described  by  G.  Villain,  pro- 
vide an  intrabuccal  artificial  joint  with  which  a  rigid 
arm  attached  to  the  free  extremity  of  the  fragment 
articulates  (see  article  in  Odontologie). 

We  ourselves  have  designed  an  instrument  upon 


MECHANICAL  TREATMENT 


Til 


similar  lines,  the  artificial  fulcrum  being  fixed  exter- 
nally in  the  region  of  the  absent  temporo-m  axillary 
joint.  The  bony  lever  is  replaced  by  a  rigid  rod,  which 
articulates  with  the  artificial  fulcrum  and  is  firmly 
attached  to  the  mandibular  fragment. 

Such  an  instrument  as  this  should,  in  our  opinion, 
be  worn   only  during 
a  meal. 

At  our  suggestion 
MM.  Granier,  Bosano, 
and  Audibert  con- 
structed several  appli- 
ances conforming  to 
a    different   principle. 

« 

Here  the  elevator 
power  which,  owing  to 
the  break  in  mandi- 
bular continuity,  had 
been  lost,  is  recon- 
veyed  to  the  free  ex- 
tremity of  the  frag- 
ment. 

Fig.  82  represents 
an  apparatus  of  this  type.  When  the  muscles 
contract,  the  flexible  cable  is  extended;  it  draws 
upwards  and  into  good  occlusion  the  free  ex- 
tremity of  the  fragment,  which  is  thus  enabled 
to  perform  masticatory  movements  along  its  entire 
length. 

These  mechanisms  are  still  very  new  and  investiga- 


FiG.  81. — Jointed  crank  with  arti- 
culated surfaces.  The  lower  arm  of 
this  crank  is  a  bar  of  cast  silver  with 
articulated  surfaces  which  assist  in 
mastication  and  serve  to  fix  occlusion. 


722     FRACTURE   OF   THE  LOWER  JAW 

tion  concerning  them   is   not   complete.       They   are 
mentioned  here  only  with  reservation, 

Pseudo-arthrosis  of  the  Ramus ;  Loss  of  Substance 
at  the  Temporo-mandibular  Joint.— These  pseudo- 
arthroses are  consequent  upon  fracture  of  the  ramus 


Fig.  82. — Apparatus  for  use  in  lateral  pseudo-arthrosis.  The 
chief  feature  of  this  apparatus  is  a  flexible  cable  attached  to  the 
sound  side  which,  at  each  movement  of  occlusion,  is  extended 
and  transmits  to  the  extremity  of  the  fragment  an  appreciable 
force.  Extension  is  effected  by  means  of  a  system  of  pulleys.  The 
apparatus  may  be  rendered  removable  if  desired. 

with  large  loss  of  substance.  They  are  characterised 
by  malocclusion  of  a  very  specific  type,  which  has  been 
described  in  an  earlier  chapter  (figs.  21  and  21a). 

The  malposition  resembles  that  seen  in  extensive 
traumatic    lesion    of    the    temporo-mandibular    joint 


MECHANICAL  TREATMENT  723 

(destruction  of  the  condyle  and  of  the  glenoid  cavity). 
The  method  of  treatment  is  equally  applicable  to  both 
classes  of  case. 

In  pseudo-arthrosis  of  the  ramus,  when  the  elevator 
muscles  are  contracted  the  elevation  of  the  mandible 
is  not  equal  on  both  sides,  in  spite  of  the  fact  that 
muscular  action  is  equal. 

The  fractured  ramus  drops  in  such  a  way  that  the 
fragments  are  brought  together  along  the  entire  length 
of  the  breach.  This  movement  is  shared  by  the 
horizontal  branch,  with  the  result  that  the  dental  arches 
of  the  fractured  side  meet  prematurely,  the  teeth  of 
the  sound  side  being  separated  by  a  varying  interval. 
The  elevator  muscles  of  the  sound  side  continue  to 
contract,  and  occlusion  is  eventually  effected  upon  this 
side  also. 

This  occlusion  in  two  parts  is  characteristic  of  the 
lesion.  It  may  be  associated  with  retraction  and 
lateral  deviation  of  the  fractured  side,  but  these  dis- 
placements are  secondary  and  always  little  marked. 

The  apparatus  designed  to  remedy  this  pseudo- 
arthrosis should,  in  the  first  place,  limit  the  action  of 
the  elevator  muscles  and  the  elevation  of  the  mandible 
upon  the  fractured  side.  It  should  also,  where  neces- 
sary, force  it  into  occlusion. 

The  crank  with  jointed  arms  and  double  stops,  as 
described  by  Villain,  corresponds  to  these  therapeutic 
indications  (fig.  83). 

In  elevator  movements  of  the  mandible  the  posterior 
arm  encounters  the  superior  stop,  which  conveys  a 


724      FRACTURE  OF   THE  LOWER  JAW 

propulsive  movement  and  thus  corrects  •  the  lateral 
deviation  and  the  retraction.  The  distal  prolongation 
of  the  lower  arm  comes  into  contact  with  the  inferior 
stop,  thus  preventing  abnormal  elevation  of  the 
mandible.  Finally,  when  the  mandible  is  in  occlusion, 
the  extremity  of  the  rod  of  the  crank  comes  to  rest  at 
the  bottom  of  the  cylinder  and  thus  completes  the 
action  of  the  stops. 

This  description  applies  to  the  crank  in  its  definitive 
form.  It  is  frequently  possible  to  employ  this  form 
from  the  first.  It  is,  however,  sometimes  necessary, 
for  purposes  of  examination  and  regulation,  to  employ 
the  form  shown  in  fig.  84. 

In  the  latter,  crank,  arms,  and  stops  may  be  modified 
in  every  kind  of  way  to  produce  elongation  or  curtail- 
ment. The  operator  is  thus  enabled  to  alter  the 
dimensions  and  relationships  of  the  different  pieces 
experimentally,  and  by  this  means  to  adjust  the  appara- 
tus to  the  necessary  requirements. 

A  "  stop-guide  "  is  also  recommended  by  G.  Villain. 
As,  however,  we  have  had  no  opportunity  of  tes'^ing 
it,  we  shall  not  describe  it  here. 

We  have  already  had  occasion  to  mention  a  case  in 
which  complete  disappearance  of  the  condyle  with  its 
neck  was  not  attended  by  functional  derangement 
of  any  description.  It  is  hardly  probable  that  in  a 
case  of  this  kind  the  missing  portion  of  bone  could 
have  been  reconstituted.  We  must  therefore  assume 
a  sipecies  of  muscular  adaptation  to  compensate  for 
th©  missing  bony  substance.     It  is  reasonable  to  assume 


Fig.  83. — Crank  with  lever  and  two  stops  for  the  treatment  of 
pseudo-arthrosis  of  the  ramus  or  loss  of  substance  at  the  temporo- 
mandibular joint.  This  is  a  passive  crank  (fig.  75)  attached  to 
two  rigid  arms,  one  vertical  the  other  horizontal,  which  are  jointed 
at  the  crank  heads  and  jointed  together.  To  the  upper  splint  a 
stop  is  attached  which,  in  movements  of  occlusion,  bears  on  the 
vertical  arm  of  the  lever  and  produces  a  forward  movement  of 
propulsion.  To  the  lower  splint  a  stop  is  also  attached  which, 
,  in  movements  of  occlusion,  bears  on  the  extremity  of  the  horizontal 
arm  of  the  lever,  thus  limiting  abnormal  tendency  of  the  mandible 
to  rise.  The  latter  movement  is  due  to  loss  of  substance  of 
the  ramus  or  of  the  temporo-mandibular  joint,  and  produces  pre- 
mature contact  of  the  dental  arches  of  the  fractured  side.  The 
play  of  the  lower  arm  of  the  lever  counteracts  this  movement  and 
regulates  it  in  such  a  way  that  interdental  contact  is  simultaneous 
along  the  entire  length  of  the  dental  arches. 

Fig.  84. — Active  crank  with  lever  and  stops.  This  is  a  kind  of 
preUminary  to  the  form  shown  in  fig.  83.  The  rods  of  the  crank, 
lever  arms,  and  stops  are  threaded  and  fitted  with  nuts.  By  this 
means  the  dimensions  are  varied  and  the  form  most  suitable  to  the 
individual  case  is  obtained  experimentally.  From  the  design 
obtained  in  this  manner  the  definitive  apparatus,  as  shown  in  fig,  83, 
is  constructed. 

725 


726     FRACTURE  OF  THE  LOWER  JAW 

that,  after  a  given  time,  muscular  adaptation  of  this 
kind  may  develop  under  the  influence  of  the  crank, 
and  that  the  crank  would  then  become  superfluous. 
Hence  the  prognosis  in  these  pseudo-arthroses  would 
be  more  favourable  than  in  the  lateral  and  median 
forms.  This,  be  it  understood,  is  hypothesis  ;  experi- 
ence in  these  cases  is  too  recent  for  a  categorical 
statement  to  be  permissible. 

Loss  of  Substance  amounting  to  almost  the  entire 
Mandible. — ^It  is  cases  of  this  class  which  make  the 
greatest  demand  upon  the  ingenuity  of  the  practitioner. 
We  can  only  give  the  general  lines  upon  which  treat- 
ment should  be  conducted.  Each  case  demands  special 
mechanisms,  and  we  give  the  results  of  our  experience 
with  a  certain  number  of  these. 

To  obtain  an  impression  of  the  mandibular  frag- 
ments is  frequently  a  very  complicated  proceeding  and 
one  that  requires  several  sittings.  The  chief  endeavour 
should  be  to  obtain  as  faithful  a  reproduction  as 
possible  of  all  fibrous  bands  and  bony  projections  likely 
to  favour  retention. 

The  base  of  the  mechanism  should  be  in  cast  metal. 
It  should  take  advantage  of  the  slightest  bony  or 
fibrous  elevation  for  purposes  of  anchorage.  The 
artificial  teeth  are  attached  to  it  later  by  vulcanised 
india-rubber.  Retention  may  be  aided  by  springs 
attached  to  the  upper  jaw  in  the  manner  described 
above.  In  certain  cases  the  crank  with  springs 
described  by  G.  Villain  (Interallied  Dental  Congress, 
1916)  is  indicated. 


MECHANICAL  TREATMENT  727 

A  badly  shattered  jaw  is  sometimes  accompanied  by 
marked  constriction  of  the  buccal  opening.  This 
constitutes  a  serious  obstacle  to  the  taking  of  im- 
pressions and  the  application  of  mechanisms.  In  these 
cases  the  impression  should  be  taken  in  several  portions 
and  the  apparatus  should  be  constructed  in  several 
piedes,  in  the  manner  described  formerly  by  Claude 
Martin  and  Delair,  and  more  recently  by  Martinier  and 
Roy  {L'Odontologie,  1916).  * 

V.    Treatment  of  Malocclusion 

Where  malocclusion  is  due  to  vicious  union  as  the 
result  of  large  loss  of  substance,  surgical  intervention 
is  indicated.  Oblique  osteotomy  would  appear  to  be 
the  best  method.  It  has  frequently  been  practised 
by  Sebileau  with  satisfactory  results. 

In  other  cases,  notably  the  deviation  known  as 
bouche  de  chantre  de  village,  the  best  method  is  by 
early  prosthetic  treatment. 

The  apparatus  employed  for  the  treatment  of  lateral 
fracture  should  always  permit  of  intermaxillary 
anchorage,  in  order  that  any  tendency  to  lateral 
deviation  may  be  counteracted.  The  mechanism 
shown  in  fig.  64  fulfils  this  requirement. 

Where  the  vicious  position  is  already  established, 
treatment  is  more  complicated  and  is  bound  to  take 
a  long  time. 

The  apparatus  which  most  nearly  corresponds  to 
the  indications  is  the  crank. 


728     FRACTURE  OF  THE  LOWER  JAW 

It  is  not  always  indicated  in  the  earlier  stages  of 
treatment.  In  certain  extreme  cases,  where  deviation 
is  not  readily  remediable,  the  jaws  should  at  first  be 
immobilised  by  the  apparatus  shown  in  figs.  69  and 
70.  By  this  means  the  vicious  position  is  partially 
corrected  from  the  start.  Later  on  the  ligatures  are 
tightened  every  eight  days,  in  such  a  way  that  the 
dental  arches  are  gradually  brought  into  occlusion. 
Occlusion  is  maintained  during  a  varying  period,  the 
ligatures  being  removed  from  time  to  time  to  ascertain 
the  results  of  treatment. 

The  crank  is  not  employed  until  the  movements 
have  become  more  supple  and  the  reduction  of  the 
vicious  attitude  can  be  effected  with  slight  manual 
effort. 

The  crank  is  intended  to  counteract  the  lateral 
deviation,  which  is  more  pronounced  when  the  mouth 
is  open.  It  should  at  the  same  time  effect  normal 
occlusion  when  the  jaws  are  closed.  Thus  its  function 
is  that  of  a  guide. 

A  passive  guide  (fig.  75)  generally  fulfils  all  require- 
ments. It  is  attached  to  the  fractured  side  in  the 
usual  manner,  and  as  little  play  as  possible  is 
allowed  to  the  articulations  at  the  crank-heads  as 
well  as  to  the  telescope.  The  latter  is  regulated 
in  such  a  way  that  when  normal  occlusion  is  ob- 
tained the  rod  comes  to  rest  at  the  bottom  of  the 
tube. 

Occasionally  two  cranks  are  necessary,  one  at  each 
side.     By   this    means    it    is    possible    to    counteract 


MECHANICAL   TREATMENT 


729 


strong  muscular  opposition,  as  well  as  to  obtain  a  better 
occlusion  (fig.  85). 

In  cases  of  this  sort  the  lever-crank  is  very  useful. 
It  is  a  more  resistant  guide  th«,n  the  simple  crank  and 
is,  for  that  reason,  frequently  indicated  here. 

The  methods  described  give  excellent  results  in  this 
sense,  that  they 
rapidly  reduce  de- 
viations which  are 
sometimes  very 
marked,  while  at 
the  same  time  they 
permit  of  a  practi- 
cally normal  diet. 
But  it  must  not  be 
supposed  that  a 
malposition  cor- 
rected is  always  a 
malposition  cured. 
Before  an  absolute 
cure  is  obtained,  the 
muscular  hyper- 
tonicity     must    be 

counteracted  for  a  long  time  by  the  influence  of  the 
crank.  Every  now  and  then  the  apparatus  is 
removed  for  the  purpose  of  testing  whether  the 
patient  is  able  to  correct  the  vicious  attitude  spon- 
taneously. Not  until  he  has  acquired  the  faculty  of 
contracting  his  masticatory  muscles  synergically  can 
he  be  regarded  as  cured  and  relieved  of  his  crank. 


Fig.  85. — Double  crank  for  the  treat- 
ment of  the  deviation  known  as  "  bouche 
du  chantre  de  village."  These  are  passive 
cranks  similar  to  those  shown  in  fig.  75 
et  seq.  They  work  as  two  active  guides 
which  counteract  the  lateral  deviation. 


730     FRACTURE  OF   THE  LOWER  JAW 

After  cure  the  patient  should  still  be  under  super- 
vision for  a  time,  for  his  condition,  similarly  to  that 
of  mandibular  constriction,  is  essentially  prone  to 
relapse.  Moreover,  the  co-operation  of  the  patient  is 
not  always  to  be  depended  upon. 

On  the  slightest  sign  of  relapse  the  crank  is  replaced. 
Lateral  deviation  may  be  prevented  by  using  a  lateral 
guide,  supported  by  a  bridge  attached  to  the  sound  side. 

This  malocclusion  consequent  upon  mandibular  frac- 
ture is  referable  to  two  primary  causes. 

In  some  cases  it  is  associated  with  very  marked 
anatomical  lesions  of  the  mandible,  deformities  which 
are  amenable  to  prosthetic  treatment  where  union  is 
not  far  advanced,  or  which  demand  surgical  interven- 
tion if  the  ossification  of  the  callus  is  definitive. 

In  other  cases  malocclusion  is  the  outcome  of 
dynamic  derangement  of  the  masticatory  muscles,  the 
lack  of  co-ordination  in  their  action  producing  the 
specific  distortion  known  as  bouche  du  chantre  de 
village.  The  length  of  time  required  for  treatment 
depends  upon  the  length  of  time  the  condition  has 
lasted.  Treatment  should  be  purely  prosthetic,  and  the 
most  efficacious  mechanism  is  the  crank. 


VI.    MechanIco-therapeutic  Treatment  OF  Myo- 
tonic Constriction  of  the  Maxill-s 

The  method  of  treatment  now  to  be  described  is 
more  particularly  indicated  in  the  form  of  closure  of 
the  jaws  most  commonly  observed,  namely,  the  myo- 


Fio.  86. 


< 


r-      <»       /XS     , 


Fio.  87. 


Fio.  88. 

Figs.  86,  87,  88. — ^-4',  metallicarches  jointed  at  J57JE?' and  fvirnished 
with  splints  DD',  by  which  the  power  of  the  springs  BB'  is  trans- 
mitted to  the  dental  arches.  GC,  threaded  and  graduated  rods 
with  flanged  screw-nuts  PF\  by  which  the  action  of  the  springs 
is  modified.     Their  graduation  shows  the  progress  made. 

731 


732      FRACTURE  OF   THE  LOWER  JAW 

tonic.  If  undertaken  early,  before  sclerotic  or  cica- 
tricial lesions  have  become  definitely  established,  it 
is  very  efficacious  in  constriction  due  to  myositis  of  the 
masticatory  muscles  and  to  lesions  of  the  temporo- 
mandibular joint. 

Our  patients  always  receive  mechanico-therapeutic 


Fig.  88a.^-Automatic  mouth-opener,  for  the  treatment  of  closure 
of  the  jaws. 

treatment  twice  a  day.  Each  sitting  lasts  for  about 
half  an  hour,  and  the  apparatus  employed  is  one  which 
we  have  had  in  use  for  some  time  and  which  is  shown 
in  figs.  87  and  88.     Its  qualifications  are  as  follows  : 

The  base  of  support  is  distributed  over  the  entire 
length  of  both  dental  arches  by  means  of  special  adjust- 
able splints. 


MECHANICAL   TREATMENT  733 

The  springs  which  convey  the  expansive  force  are 
regulated  by  flanged  screw  nuts. 

Each  day's  progress  is  registered  by  means  of  a 
graduated  rod. 

In  our  view  it  is  essential,  especially  in  myotonic 
cases,  that  the  gap  between  the  jaws  effected  at  each 
sitting  shall  be  maintained  by  means  of  a  wooden 
wedge  introduced  between  the  teeth  and  kept  there 
until  the  next  sitting.  This  measure  eflFectually 
counteracts  the  hypertonicity  of  the  elevator  muscles. 
It  produces  the  "  inverse  attitude,"  a  therapeutic 
principle  regarded  as  of  extreme  importance  by 
neurologists  interested  in  acromyotonia. 


CHAPTER   VI 

SURGICAL  TREATMENT 

In  the  last  chapter  the  technique  and  the  clinical  results 
of  prosthetic  treatment  were  described.  In  mandibular, 
as  in  the  majority  of  other  fractures,  operative  treat- 
ment should  not  be  resorted  to  until  treatment  by 
mechanical  apparatus  has  failed.  It  is  in  fact  indicated 
in  pseudo-arthrosis  alone. 

For  the  last  eighteen  months  we  have  been  in  charge 
of  a  maxillo-facial  department  with  a  minimum  of 
150  patients.  During  this  period  eighteen  patients 
only  have  received  surgical  treatment.  This  is  proof 
positive  that  we  ourselves  have  carried  out  the  principle 
which  we  advocate,  namely,  never  to  operate  except 
in  definitive  pseudo-arthrosis. 

Two  forms  of  surgical  intervention  are  indicated. 

Where  it  is  advisable  to  draw  the  two  fragments  of 

bone   together,   osteo-synthesis   should   be  practised. 

Where  the  loss  of  substance  is  very  extensive,  however, 

osteo-synthesis  is  either  not  attended  by  results  or  it 

yields  results  which  are  functionally  imperfect.     In 

such  cases  the  niethod  should  be  reinforced  by  the 

bony  graft.     The  object  of  this  book,  however,  is  to 

describe  the  positive  results  of  the  treatment  of  war 

734 


SURGICAL   TREATMENT  735 

wounds,  and  the  number  of  bony  grafts  performed 
upon  the  mandible  is  too  few  to  permit  of  definitive 
conclusions.  For  this  reason  the  subject  will  be  only 
briefly  dealt  with  here. 

Those  of  our  cases  in  which  osteo-synthetic  methods 
have  been  employed  have  all  been  lateral  fractures. 
This  is  due,  not  to  special  suitability  of  the  condition, 
but  to  the  fact  that  the  method  has  not  been  indicated 
in  the  cases  of  median  and  retromolar  fracture  which 
have  come  under  our  notice. 

Union  is  undoubtedly  more  frequent  in  median 
fracture  than  in  other  types.  This  is  attributable  to 
the  fact  that  the  equal  length  of  the  fragments 
facilitates  their  inclination  towards  one  another.  It 
is  true  that  vicious  union  may  result,  but  pseudo- 
arthrosis is  excluded.  It  may  be,  too,  that  the  ten- 
dency to  intervention  on  the  part  of  the  muscular 
masses  in  the  immediate  neighbourhood  is  slighter. 
However  that  may  be,  one  thing  is  certain,  namely, 
that  pseudo-arthrosis  in  median  fracture  is  invariably 
associated  with  grave  loss  of  substance,  such  as  cannot 
be  remedied  by  Dsteo-synthetic  methods. 

Similar  reasons  hold  good  in  the  case  of  fracture  of 
the  angle  and  of  the  ramus.  These  fractures  either 
unite  or  the  loss  of  substance  is  so  extensive  that 
osteo-synthesis  is  impracticable. 

I.     Osteo-Synthesis 

In  the  case  of  fracture  of  the  limbs  the  bony  extremi- 
ties may  be  brought  together  in  various  ways  :    by 


736       FRACTURE  OF   THE  LOWER  JAW 

flexible  ligature,  metal  ligature,  bolts,  etc.  In  fracture 
of  the  mandible  several  of  these  methods  are  excluded. 
The  only  permissible  methods  are  ligature  with  metal 
wire,  and  the  application  of  a  screw-plate.  The  latter 
is  preferable,  because  it  procures  a  greater  rigidity  and 
a  better  co-adaptation  of  the  fragments.  We  recognise, 
however,  that  after  the  fragments  have  been  brought 
together,  the  maintenance  of  the  jaws  in  occlusion 
by  methods  which  we  shall  describe  later,  contributes 
very  favourably  to  the  contention  of  the  fracture  site, 
and  for  this  reason  we  do  not  entirely  reject  the  wire 
ligature.* 

It  must  be  understood  that  the  indications  for 
surgical  treatment  are  exceptional.  The  special 
methods  described  in  the  previous  chapter  result  in 
the  union  in  good  position  of  90  per  cent,  of  fractures 
with  loss  of  substance,  and  100  per  cent,  of  fractures 
with  no  loss  of  substance.  The  results  obtained  in  the 
maxillo-facial  department  of  the  medical  centre  at 
Marseilles  are  such  that  the  proportion  of  patients 
returned  to  the  army  has  never  been  less  than  90  per 
cent.,  and  has  frequently  reached  95  per  cent. 

OPERATIVE  TECHNIQUE 

Here,  as  elsewhere,  asepsis  is  essential,  and  the 
technique  we  are  about  to  describe  is  formulated  with 
the  object  of  attaining  it.     But  it  must  not  be  for- 

1  L.  Imbert  and  P.  Real,  "  Traitement  des  Pseudo-arthroses  du 
maxillaire  inf^rieur  par  I'ost^o-syn these."  Soc.  de  Chir.,  March  29th, 
1916,  and  Interallied  Dental  Congress,  November,   1916. 


SURGICAL  TREATMENT  737 

gotten  that  union  is  obtainable  even  at  an  infected 
fracture  site.  Good  results  in  the  case  of  the  humerus 
have  been  published  by  Dujarier,  and  we  ourselves  have 
effected  union  where  a  sinus  existed  at  the  site  of  opera- 
tion. On  the  other  hand,  union  by  first  intention  is  not 
invariably  a  therapeutic  success.  In  the  case  of  the 
mandible,  the  infective  complications  of  osteo-synthetic 
operation  are  never  serious.  We  have  never  lost  a 
patient  nor  have  we  ever  had  cause  fpr  serious  anxiety. 
Hence,  where  local  infection  is  present  it  is  rarely 
necessary  to  remove  the  metal  plate ;  it  is  usually 
sufficient  to  remove  the  sutures. 

Age  of  the  Fracture. — ^At  what  stage  is  operation 
indicated  ?  As  we  have  shown,  the  surgeon  should  not 
intervene  until  pseudo-arthrosis  is  established.  This 
condition  depends  either  upon  the  amount  of  sub- 
stance lost,  which  is  not  less  than  2-3  cm.,  or  upon 
the  failure  of  prosthetic  measures.  The  latter  should 
have  been  employed  under  suitable  conditions  and 
should  have  succeeded  in  bringing  the  fragments 
together.  A  fracture  in  which  the  fragments  are 
permanently  separated  may  unite  by  the  agency  of 
bony  projections,  but  the  conditions  are  not  favour- 
able to  union.  To  obtain  union  in  obstinate  cases  an 
apparatus  should  be  employed  which  will  bring  the 
fragments  together.  It  should,  moreover,  be  worn 
for  a  sufficient  length  of  time.  In  our  opinion  the 
minimum  is  three  months,  dating  from  the  moment 
when  the  lesions  of  the  soft  parts  have  so  far  progressed 
that  complications  on  their  part  are  no  longer  to  be 


738      FRACTURE  OF   THE  LOWER  JAW 

anticipated.  Thus,  pseudo-arthrosis  is  not  presented 
until  after  a  period  of  at  least  six  months.  Inter- 
vention before  this  date  does  not  expose  the  patient 
to  any  serious  danger,  but  the  results  of  such  inter- 
vention must  be  regarded  as  surgically  facile,  seeing 
that  union  could  have  been  obtained  by  means  of 
mechanisms. 

Should  operation  be  postponed  until  infection  is 
abolished  ?  Our  answer  is  emphatically  in  the  affirma- 
tive. Not  that  good  results  are  not  obtainable,  but  it 
appears  to  us  purposeless  to  act  in  the  presence  of  a 
suppuration  which,  to  say  the  least,  must  prove  in- 
convenient. Moreover,  it  is  always  easy  to  dry  up 
the  suppuration  from  a  fracture,  and  the  conditions 
presented  by  the  mandible  are  more  favourable  than 
thoBe  of  the  majority  of  bones.  A  sinus  in  connection 
with  a  fracture  is  due  to  two  causes,  namely,  the 
presence  of  dental  caries  or  of  a  sequestrum.  The 
mouth  should  be  minutely  examined  by  the  stomatolo- 
gist, and  all  fractured  roots  as  well  as  those  suspected 
of  infirmity  should  be  removed.  Where,  in  spite  of 
minute  attention,  the  sinus  does  not  close  up,  surgical 
intervention  is  indicated.  Simple  curetting,  so  fre- 
quently without  effect  in  sinuses  of  the  bones  of  the 
limbs,  usually  gives  excellent  results  here.  The 
channel  is  opened  up,  a  small  sequestrum,  the  root  of 
a  tooth,  a  tooth  itself,  removed,  and  the  sinus  closes  in 
a  few  days.  It  is  exceptional  for  a  second  curetting 
to  be  necessary. 

Occasionally  there  is  a  hampering  discharge,  salivary 


SURGICAL  TREATMENT  739 

rather  than  purulent.  This  is  remedied  as  follows. 
The  little  orifice  is  localised  by  watching  the  patient 
during  mastication.  The  fine  point  of  galvano- 
,  cautery  is  introduced  as  far  as  possible  into  the 
passage  and  is  heated  when  the  point  is  in  position. 
If  well  cauterised  in  this  manner,  the  fistula  closes  in  a 
few  days. 

These  minor  interventions  may  with  advantage  be 
carried  out  during  the  prosthetic  period  of  treatment. 
Where  the  rare  opportunity  occurs  of  taking  over  a 
patient  from  the  first,  by  careful  attention  to  these 
details  the  period  of  treatment  may  sometimes  be 
reduced  to  four  months.  On  the  other  hand,  it  must 
obviously  be  lengthened  by  the  amount  of  time  spent 
under  less  favourable  conditions. 

Preparation  for  Operation. — It  is  important  that  the 
buccal  cavity  should  not  be  opened  up  by  operative 
manipulation,  for  this  is  certain  to  lead  to  infection 
of  the  wound.  It  is  difficult  to  prevent,  however,  where 
the  root  of  a  tooth  is  implanted  in  the  extreme  border 
of  a  fragment.  For  this  reason  we  make  a  preliminary 
exploration  of  the  fracture  site.  Roots  at  the  extreme 
edge  of  fragments  are  carefully  removed  and  the  gum 
is  allowed  to  heal,  usually  a  matter  of  about  fourteen 
days.  In  the  first  two  operations  which  we  performed, 
we  opened  the  mucosa,  but  since  taking  these  pre- 
cautions such  an  accident  has  not  occurred,  not  even 
where  the  denudation  of  the  fractured  surfaces  was 
very  extensive. 

A  second  essential  condition  is  the  possibility  of 


740     FRACTURE  OF  THE  LOWER  JAW 

bringing  the  fragments  together.  A  reasonable  loss 
of  substance  is  presupposed  ;  it  should  not  exceed 
one  or  two  teeth,  in  rare  cases  three.  From  this  point 
of  view  prosthetic  treatment,  even  where  unsuccessful, 
is  of  extreme  utility.  In  a  previous  chapter  we  have 
expressed  the  view  that  union  is  more  important  than 
occlusion,  and  that  an  efficient  retention  apparatus 
should  bring  the  fragments  together,  thus  effacing  the 
loss  of  substance.  It  should  prepare  the  ground  for 
surgical  intervention,  for,  as  we  shall  show  later,  the 
success  of  osteo-synthetic  methods  in  mandibular  as 
in  other  fracture,  depends  upon  the  bringing  together 
of  the  fractured  surfaces.  The  superiority  of  osteo- 
synthesis does  not  depend  upon  the  fact  that  it  is 
applicable  where  there  is  large  loss  of  substance.  From 
this  point  of  view  its  indications  do  not  differ  from  those 
of  prosthetic  appliances.  But  the  latter  sometimes  fail 
to  effect  union  even  where  they  have  succeeded  in 
abolishing  the  interfragmentary  gap.  The  primary 
causes  of  this  failure  are  not  always  appreciable,  but 
the  immediate  causes  appear  to  lie  in  the  pointed 
configuration  of  the  broken  ends  and  the  presence  of 
a  more  or  less  thickened  fibrous  obstruction.  The 
objects  of  operation  are  :  to  remove  this  obstruction, 
to  make  a  fresh-cut  surface  to  the  broken  ends,  and  to 
bring  them  into  contact.  It  is  evident  that  these 
results  are  more  easily  obtainable  where  the  preliminary 
prosthetic  treatment  has  fulfilled  its  purpose. 

Anaesthesia. — In  a  former  chapter  we  showed  that 
mandibular  fracture  presents  a  mental  zone  of  anses- 


SURGICAL  TREATMENT  741 

thesia  affecting  the  gum  and  mucous  membrane  of 
mouth,  as  well  as  the  teeth  of  the  anterior  fragment 
and  the  anterior  fragment  itself.  Thus  anaesthesia  of 
the  posterior  fragment  and  of  the  soft  parts  is  all  that 
is  required.  This  result  might  undoubtedly  be  obtained 
by  local  anaesthesia,  though  the  method  is  one  which 
we  have  never  employed.  In  one  case  we  combined 
local  and  regional  anaesthesia  by  direct  action  upon 
the  mandibular  n6rve.  With  Sicard's  able  assistance 
the  operation  was  successfully  completed.  The  method 
is,  however,  only  practicable  in  the  case  of  very  vigorous 
subjects.  With  this  one  exception  we  have  always 
employed  general  anaesthesia. 

Ether  or  chloroform  ?  The  abundant  salivation 
almost  invariably  provoked  by  ether  seems  to  us  a 
definite  contra-indication  to  its  employment.  For 
this  reason  we  have  always  used  chloroform,  but  even 
with  this  anaesthetic,  the  near  presence  of  the  anaes- 
thetist constitutes  a  serious  embarrassment.  To 
reduce  the  inconvenience  as  far  as  possible  we  employ 
Ricard's  old-fashioned  apparatus,  which  obviates  the 
necessity  for  constantly  pouring  chloroform  on  the 
compress.  The  anaesthetist  is  instructed  to  keep  his 
hand  and  fingers  well  within  the  limits  of  the  mask. 
By  observing  these  precautions,  the  number  of  the 
possible  channels  of  infection  arising  from  the  vicinity 
of  the  mouth  and  the  anaesthetic  manipulations  is 
certainly  reduced. 

Incision. — The  position  of  the  incision  is  obviously 
dependent  upon  that  of  the  fracture-site.     We  em- 


742     FRACTURE  OF   THE  LOWER  JAW 


ployed  at  first  a  rectilinear  incision  corresponding  to 
the  inferior  border  of  the  maxilla,  but  the  method 
presented  certain  drawbacks,  and  we  have  since  aban- 
doned it.  Sutures  in  this  position  are  immediately 
over  the  plate  and  screws,  a  condition  very  unfavour- 
able to  good  cicatri- 
sation. Moreover,  in 
spite  of  all  precau- 
tions, the  secretions 
from  the  mouth  tend 
to  soil  the  dress- 
ings. The  further 
the  incision  is  re- 
moved from  the 
mouth,  the  better  the 
chance  of  avoiding 
such  a  contingency. 
We   prefer   a    curved 

Fio.  89. — Diagram  showing  the  usual  ...                r- 

position  of  the  fragments ;  falling  of  the  mcision         (ng.         89), 

posterior  fragment;  extremities  in  irre-  -^i^   xi^      antpHnr  py- 

gular  points.    The  figure  shows  the  Hne  ^^^^   ^^^   anterior   ex- 

of  incision  ;  curved  and  with  the  con-  tremitv     at     the      me- 
cavity  uppermost ;  extending  from  the 

vicinity  of  the  symphysis  to  that  of  dian    line    or    the    in- 
the  angle. 

ferior    border    of   the 

bone,  and  the  posterior   extremity   at   the   angle   of 

the  jaw. 

By  this  means  a  flap  is  raised  which  should  be  well 
freed  to  facilitate  suture  after  operation. 

Cicatrices  should  be  avoided,  especially  those  ex- 
tending under  the  curve  of  the  incision.  We  have 
occasionally  seen  complete  mortification  of  the  flap, 


SURGICAL  TREATMENT 


743 


the  circulation  having  been  arrested  by  the  cicatrix. 
The  curved  incision  completes  the  anaemia,  and  the 
entire  flap  is  thus  deprived  of  nutrition.  Where  a 
cicatrix  occupies  this  disadvantageous  position,  a 
band  of  healthy  skin  should  be  left  intact  between  it 
and  the  incision  in  order  to  effectuate  circulation. 

Exposure  of  the 
Fracture  Site. — The 
flap  is  raised  by 
large  strokes  of  the 
bistoury  until  the 
fracture  site  is  well 
exposed.  A  thread 
is  passed  through  it, 
the  extremities  of 
which  are  attached 
to  a  rather  heavy 
forceps,  which  forms 
the  counter-weight 
and  acts  as  an  au- 
tomatic retractor 
(fig.  90). 

Denudation  of  the  fragments  follows.  A  stroke  of 
the  bistoury,  penetrating  well  down,  is  carried  along 
the  inferior  border  of  the  bone,  and  separation  is 
effected  by  means  of  the  scraper.  It  goes  without 
saying  that  haemorrhage  is  abundant .  Unless  the  facial 
has  been  destroyed  by  the  injury,  it  bleeds  very  freely. 
Moreover,  regions  which  have  formed  the  seat  of  pro- 
longed inflammatory  trouble  remain  very  vascular. 


Fig.  90. — Diagram  showing  the  flap 
turned  back  and  the  fracture  site 
exposed. 


744      FRACTURE  OF  THE  LOWER  JAW 

The  haemorrhage  is  easily  arrested  ;  we  usually  ligature 
only  the  facial. 

The  scraper  should  be  employed  for  denudation  of 
the  fragments.  As  always,  Farabeuf's  curved  scraper 
is  a  valuable  instrument.  It  is  advisable  to  begin 
with  the  posterior  fragment,  which  is  usually  more 
easily  decorticated.  The  external  surface  is  first 
exposed,  then  the  end  of  the  fragment,  which  is  usually 
pointed  and  irregular,  and  then  the  internal  surface 
is  denuded.  Finally  the  superior  border  is  exposed, 
taking  care  not  to  expose  too  much  in  order  to  avoid 
making  a  passage  into  the  buccal  cavity. 

In  the  case  of  the  anterior  fragment,  the  inequalities 
of  the  external  face  are  patiently  followed  with  the 
tip  of  the  scraper.  The  point,  the  internal  face,  and 
the  superior  border  are  all  successively  treated  in  the 
same  manner.  The  anterior  fragment  after  scraping 
rarely  presents  the  neat  and  satisfactory  appearance 
of  the  posterior  fragment. 

When  the  two  fragments  are  denuded  and  an  attempt 
is  made  to  bring  them  together,  it  will  be  found  that 
the  fibrous  obstruction  by  which  they  are  separated 
has  a  pronounced  tendency  to  interpose.  This  must 
be  cut  away  with  the  scissors  until  nothing  remains  to 
hinder  the  contact  of  the  fractured  surfaces. 

Fresh  cutting  of  the  Fractured  Surfaces. — ^A  further 
difficulty  now  presents  itself.  The  surfaces  of  frag- 
ments are  habitually  irregular,  and  are  usually  pointed. 
Merely  to  cut  away  these  surfaces  would  leave  two 
bony  points  in  contact.     The  sole  method  is  to  bring 


SURGICAL  TREATMENT 


745 


down  the  point,  and  this  must  be  executed  with 
extreme  discretion  or  the  breach  will  be  irretrievably 
widened.     The  removal  of  about  1  cm.  should  suffice. 

With  an  electric  lathe  and  some  dentist's  burrs  the 
manoeuvre  is  a  simple  one  ;  with  the  ordinary  surgical 
outfit  it  is  really 
difficult,  and  is 
usually  imper- 
fectly performed. 
In  good  hands,  a 
burr  such  as  that 
shown  in  fig.  91 
gives  rapid  and 
satisfactory  re- 
sults. The  arm  of 
the  electric  lathe 
is  of  coursecovered 
with  a  piece  of 
sterile  linen,  and 
the  hand-piece 
and  burrs  are 
sterilised  with  the 
other  instruments. 

Application  o!  the  Plate. — The  plates  which  we  prefer 
are  of  gilt  German  silver.  It  is  true  that  they  are 
not  as  resistant  as  Lambotte's  plate,  but  the  bone  with 
which  we  have  to  deal  is  not  uniform  in  its  curve.  It 
is  almost  flat  in  places,  and  becomes  more  convex  as 
it  approaches  the  median  line.  Hence  a  plate  must 
be  employed  the  curve  of  which  may  be  modified  by 


Fig.  91. — Diagram  showing  the  manner 
of  freshening  the  fractured  surfaces  by 
means  of  a  burr  on  an  electric  lathe.  The 
fragment  to  be  cut  is  held  with  the  curved 
scraper 


746     FRACTURE  OF   THE  LOWER  JAW 

means  of  strong  pliers.     After  operation  the  mandible 
is  immobilised  by  attachment  to  the  upper  jaw,  hence 
the  maintenance  of  reduction  is  not  entirely  thrown 
upon  the  plate,  and  its  lack  of  absolute  rigidity  is  not 
an  insuperable  drawback.     It  is  usually  fixed  in  place 
by  means  of  four  screws,  two  in  front  and  two  at  the 
back.     A  point  of  paramount  importance  is  to  avoid 
the  roots  of  the  teeth.    A  root  which  has  been  injured 
by  a  screw  may  easily  prove  a  source  of  infection  to  the 
fracture  site.      For  this  reason  the  plate  is  not  applied 
to  the  centre  of  the  external  face  of  the  fragments, 
but  along  their  inferior  border,  the  screws  being  inserted 
about    1    cm.    above  the    edge.     The    precautionary 
measure  of  removing  the  marginal  teeth  still  further 
limits  the  danger. 

Before  applying  the  plate  the  surgeon  should  assure 
himself  that  the  two  fragments  may  be  easily  brought 
together.  Contact  is  essential,  and  an  interval, 
though  only  of  a  millimetre,  must  almost  inevitably 
compromise  the  results.  Where  there  is  difficulty  in 
bringing  the  fragments  together,  a  hole  should  be 
bored  in  each  fragment,  through  which  a  strong  wire 
is  passed.  The  latter  must  permit  of  powerful  traction, 
and  must  maintain  contact  until  the  plate  is  screwed 
into  position. 

These  precautions  having  been  taken,  and  the  plate 
bent  into  shape  with  a  pair  of  strong  pliers,  it  is 
applied.  A  hole  corresponding  to  the  posterior  screw- 
hole  of  the  plate  is  bored  in  the  posterior  fragment. 
The  hole  is  made  with  a  burr  on  an  electric  lathe,  its 


SURGICAL  TREATMENT 


747 


size  conforming  to  the  diameter  of  the  screw.  The 
latter  is  immediately  screwed  into  place.  A  hole 
corresponding  to  one  of  the  anterior  screws  is  bored 
in  the  anterior  fragment  and  this  is  screwed  into  place. 
The  application  of  the  two  remaining  screws  is  a  simple 
matter  (fig.  92). 

One  of   the  great        /  j 

difficulties  associated 
with  pseudo-arthro- 
sis  of  the  bones  of 
the  limbs  is  the 
poor  consistency  of 
the  extremities  of 
the  bony  fragments. 
Only  too  frequently 
the  screws  fail  to 
bite,  and  their  hold 
is  very  precarious. 
Occasionally  their 
use  is  impossible  and 
ligatures  must  be 
employed,  always  an  unsatisfactory  method.  This 
complication  does  not  arise  in  the  case  of  the  mandible. 
We  have  always  found  the  bony  extremities  to  consist 
of  a  compact  and  resistant  tissue  which  gives  the 
screws  a  good  hold. 

Once  the  four  screws  are  in  position,  the  operation 
is  terminated.  A  gap  corresponding  to  the  inferior 
border  of  the  bone,  and  due  to  the  shape  of  the  frac- 
tured extremities,  is  frequently  observed.     We  have 


Fig.  92. — Diagram  showing  the  plate 
attached  by  four  screws,  two  upon  each 
fragment. 


Plate  III 


Patient  T.  Skiagram  and  explanatory  diagram.  Pseudo- 
arthrosis of  the  mandible  with  loss  of  substance.  Overriding  of  the 
fragments. 


Plate  IV 


Patient  T.  Skiagram  after  osteo  synthesis ;  reduction  of  the 
fragments;  application  of  a  metal  screw-plate.  Skiagram  and 
explanatory  diagram. 


Plate  V 


Patient  T.     Skiagram  after  union   and   removal  of   the  plate. 
Skiagram  and  explanatory  diagram. 


748      FRACTURE  OF   THE  LOWER  JAW 

endeavoured  to  fill  it  with  a  chip  taken  from  the 
posterior  fragment,  but  we  are  not  convinced  that  the 
results  of  this  little  operation  are  entirely  satisfactory. 

Sutures. — All  that  now  remains  is  to  put  back  the 
flap.  Most  frequently  it  is  thin  and  traversed  by 
cicatrices.  Nevertheless  it  should  be  sutured  along 
two  planes,  using  catgut  for  the  deeper  plane,  which 
brings  the  soft  parts  together,  and  silk  or  horsehair 
for  the  surface  stitches.  Unless  the  buccal  cavity  has 
been  opened,  drainage  is  not  required. 

This  is  the  moment  for  dental  intervention  and  the 
immobilisation  of  the  teeth  in  occlusion.  Two  align- 
ment wires  with  spurs  having  been  previously  attached 
to  the  upper  and  lower  dental  arches,  to  unite  them 
at  the  end  of  operation  by  brass  wire  ligatures  is  a 
simple  matter. 

The  wound  is  dressed  with  gauze  kept  in  place  by 
bands  of  adhesive  plaster.  The  latter  are  arranged  in 
such  a  way  that  they  form  a  sort  of  barrier  at  the  side 
of  the  mouth.  Before  coming  round  the  patient  is 
put  in  charge  of  a  nurse,  who  sees  that  the  dressings  are 
not  soiled  by  the  buccal  secretions. 

Results  of  Osteo-Synthesis 

Up  to  the  present  we  have  had  18  cases  under  obser- 
vation. Of  these  7  were  successful,  8  unsuccessful, 
and  3  are  so  recent  that  the  results  of  operation  are 
still  uncertain.  Those  cases  only  are  regarded  as 
successful  in  which  union  is  definitive.     As  in  the  case 


SURGICAL   TREATMENT  749 

of  pseudo-arthroses  of  the  limbs,  failure  is  fairly 
frequent,  but  it  must  be  borne  in  mind  that  in  all  our 
cases  the  pseudo-arthrosis  was  confirmed. 

Union  is  very  protracted,  and  this  is  in  line  with 
the  observations  of  others  of  osteo-synthesis  in  fracture 


Fig.  93. — Left  lateral  fracture  ;  pseudo-arthrosis  in  spite  of  pro- 
longed immobilisation  ;  the  skiagram  shows  the  plate  by  means 
of  which  union  is  obtained. 


of  the  long  bones.  Cases  in  which  union  is  effected  in 
two  months  may  be  regarded  as  exceptionally  favour- 
able. The  average  varies  from  three  to  four  months, 
and  we  have  known  union  delayed  for  five. 

It  is  easy  to  judge  of  the  progress  made.  We  make 
a  rule  of  removing  the  mechanism  which  effects  occlu- 
sion at  the  end  of  two  months.     By  that  time  the 


750       FRACTURE  OF   THE   LOWER  JAW 

screws  have  acquired  sufficient  play  for  it  to  be 
possible  to  judge  whether  mobility  is  still  present. 
The  apparatus  is  immediately  replaced,  and  is  removed 
every  month  for  purposes  of  investigation. 

In  hospitals  accustomed  to  the  management  of  these 


Fig.  94. — Left  lateral  fracture  with  larga  loss  of  substance  ; 
pseudo-arthrosis  in  spite  of  prolonged  immobilisation  ;  union  by 
03teo-syn  thesis. 

patients  diet  offers  no  difficulties.  It  should  consist 
of  liquid  or  semi-liquid  foods  ;  many  patients  are 
sufficiently  adroit  to  manage  minced  meat. 

Where  infection  is  present  we  always  remove  the 
plate.  We  recommend  removal  of  the  plate  in  aseptic 
cases  also,  a  course  to  which  the  greater  number  of 
patients  consent.     They  arfe  as  anxious  to  rid  them- 


SURGICAL  TREATMENT  751 

selves  of  this  foreign  body  as  if  it  were  a  fragment  of 
projectile.  Naturally,  removal  of  the  plate  does  not 
take  place  until  after  union,  or  until  after  proved  failure 
at  the  end  of  five  or  six  months. 

Plates  III,  IV,  and  V  show  the  position  of  the  frag- 
ments in  one  of  our  cases  before  and  after  osteo- 
synthesis, as  well  as  their  union  after  removal  of  the 
plate. 

II.     Bony    and    Cartilaginous    Grafts.^    Actual 

Results 

The  question  of  the  bony  graft  in  connection  with 
pseudo-arthrosis  of  all  kinds  is  still  in  course  of  study. 

We  propose  to  describe  definitive  results  only.  If 
little  is  known  of  the  ultimate  outcome  of  bone-grafting 
in  pseudo-arthrosis  of  the  bones  of  the  limbs,  still  less 
is  known  of  its  results  in  pseudo-arthrosis  of  the 
mandible.  This  is  due,  not  to  any  inherent  unsuita- 
bility  of  the  method,  but  to  the  extreme  scarcity  o\  the 
literature  of  the  subject.  We  shall  describe,  first, 
the  results  obtained  by  other  surgeons,  and  second, 
the  results  which  we  ourselves  have  obtained. 

Briefly  stated,  the  situation  is  as  follows  : 
The  term  "  bone-grafting  "  has  a  certain  biological 
significance  which  is  comparatively  definite  and  precise, 

1  Autografts  are  those  taken  from  the  subject ;  homografts 
those  taken  from  another  subject  of  the  same  species  (man)  ;  hetero- 
grafts  those  taken  from  a  subject  of  different  species  (animal). 
We  do  not  know  of  a  specific  term  for  grafts  taken  from  the  fracture 
site.     They  might  very  well  be  termed  autografts  in  situ. 


752     FRACTURE  OF   THE  LOWER  JAW 

but  from  the  surgical  point  of  view  this  is  not  the  case. 
Surgically,  the  graft  is  employed  to  fulfil  a  double 
purpose,  and  it  is  improbable  that  the  conditions  inci- 
dental to  success  are  the  same  in  both  cases. 

Sometimes  the  graft  is  employed  as  a  simple  agent 


Fig.  95. — Bone  graft.  In  this  case  the  graft  acts  as  an  agent 
of  union,  the  method  being  that  of  osteo-synthesis  in  which 
the  metal  plate  is  replaced  by  a  segment  of  bone.  The  callus  will 
be  formed  as  in  ordinary  fracture  by  the  two  fragments,  the  graft 
will  not  take  part  in  its  constitution. 

of  union  (fig.  95),  when  it  plays  the  part  of  a  bolt. 
In  such  a  case  the  surfaces  of  the  fragments  are  in 
contact  anrl  there  is  no  loss  of  substance  to  be  replaced. 
The  typical  indications  for  this  use  of  the  graft  are 
supplied  by  fracture  of  the  neck  of  the  femur.  Some 
surgeons  introduce  a  long  bony  pin  into  the  neck 


SURGICAL  TREATMENT 


753 


with  the  object  of  immobilising  the  fragments  and 
favouring  union.  The  same  method  appears  practic- 
able in  the  case  of  the  mandible,  the  graft  taking  the 
form  sometimes  of  a  pin  and  sometimes  that  of  an 
osteo-synthetic  plate  attached,  or  even  screwed,  to 
both  fragments.     It  is  evident  that  success  by  these 


Fig.  96. — Bone  graft.  Hel-e  the  graft  d9es  not  act  oiily  as  an 
agent  of  union.  The  space  between  the  fragments  is  so  consider- 
able that  union  is  not  possible  through  their  agency.  The  graft 
should  take  an  active  part  in  the  formation  of  the  callus.  It  is 
not  certain  that  it  will  do  so. 


methods  should  be  comparatively  easy.  There  is  no 
reason  to  doubt  that  a  splint  of  this  nature  may  effect 
immobilisation  and  ultimate  union  as  well  as  or  better 
than  a  metal  plate. 

Where  the  graft  is  intended  to  replace  and  to  fulfil 
the  functions  of  a  missing  portion  of  bone,  the  con- 


> 


754      FRACTURE  OF  THE  LOWER  JAW 

ditions  are  entirely  different.  In  the  case  of  the 
first  method  it  is  a  matter  of  indifference  whether  the 
transplanted  fragment  is  eventually  resorbed  or  not. 
Such  is  not  the  case  here.  The  graft  is  expected  not 
only  to  live,  not  only  to  preserve  its  essential  qualities, 
and  especially  its  solidity,  but  to  participate  actively 
in  the  processes  of  reparation  and  to  play  a  structural 
part  in  the  formation  of  the  callus.  In  our  view,  no 
proof  is  forthcoming  that  such  results  may  be  antici- 
pated with  certainty,  even  in  pseudo-arthroses  of  bones 
other  than  the  mandible.  The  solution  of  the  problem 
would  be  of  inestimable  value  to  the  therapeutics  of 
surgery. 

That  this  point  should  be  cleared  up  is  essential,  and 
it  seems  to  us  indispensable  that  all  histories  of  cases 
should  furnish  very  precise  and  explicit  details  in  this 
direction. 

There  is  yet  another  factor  which  appears  to  us  to 
have  a  primary  importance  in  its  bearing  upon  the 
definitive  results  of  bone-grafting. 

Every  one  knows,  and  we  have  more  than  once 
recalled  the  fact,  that  a  breach  in  the  mandible  of 
2  cm.,  or  even  more,  especially  when  situated  anteriorly, 
may  perfectly  well  unite  without  surgical  intervention 
by  the  simple  application  of  prosthetic  mechanisms, 
or  it  may  unite  spontaneously.  We  have  seen  cases 
where  union  has  been  effected  with  a  loss  of  3  cm.  and 
over. 

The  fact  must  not  be  lost  sight  of  that,  as  the 


SURGICAL   TREATMENT  755 

majority  of  recent  fractures  unite  without  difficulty, 
the  bony  graft  is  indicated  only  in  confirmed  pseudo- 
arthrosis. Hence,  except  where  loss  of  substance  is 
very  extensive,  grafting  should  always  be  preceded 
by  prolonged  prosthetic  treatment,  and  proof  of  the 
negative  results  of  such  treatment  should  be  forth- 
coming. 

It  is  superfluous  to  add  that,  the  object  of  grafting 
being  union,  it  cannot  be  regarded  as  successful  unless 
union  is  obtained. 

Histories  of  cases  in  which  grafts  have  been  employed 
should  then  elucidate  two  points  :  that  a  sufficiently 
long  prosthetic  treatment  has  been  employed ;  and 
that  there  is  clinical,  and  where  necessary  radiographic, 
proof  of  union. 

We  have  stated  that  osteo-synthesis  does  not  neces- 
sarily fail  when  the  wound  becomes  infected.  Many 
surgeons  have  observed  this  fact  in  connection  with 
pseudo-arthroses  of  the  limbs  ;  we  can  offer  confir- 
matory evidence  in  regard  to  the  mandible. 

Does  the  same  hold  good  in  the  case  of  the  bony 
graft  ?  We  think  not.  There  is  no  doubt  that 
a  transplanted  fragment  of  bone  may  recover  its 
vitality,  provided  that  it  acquires  intimate  contact 
with  the  tissues  by  which  it  is  surrounded.  But  if  it 
is  bathed  in  pus,  it  seems  to  us  that  it  must. inevitably 
become  a  sequestrum.  It  is  essential  to  the  future 
of  bone-grafting  that  this  point  should  be  cleared  up, 
and  we  take  this  opportunity  of  appealing  to  those 


756     FRACTURE  OF   THE  LOWER  JAW 

of  our  confreres  who  have  experience  of  the  method, 
to  publish  detailed  particulars  of  their  findings  in 
regard  to  this  all-important  matter. 

Morestin  has  applied  his  general  method  of  cartilagin- 
ous graft  to  mandibular  pseudo-arthrosis.  In  a  case 
described  before  the  Societe  de  Chirurgie  (May  31st, 
1916),  the  angle,  together  with  the  ramus,  had  been 
totally  destroyed.  The  missing  portion  was  replaced 
by  a  graft  taken  from  the  6th  and  7th  costal  cartilages. 
From  the  aesthetic  point  of  view  the  result  was 
perfect,  but  the  union  of  the  graft  with  the  bone 
was  incomplete,  the  graft  continuing  to  present  an 
obscure  mobility.  More  recently  other  similar  cases 
have  been  published  by  this  author. 

Morestin  also  proposed  {Soc.  Anat.  1902,  p.  183)  to 
treat  pseudo-arthrosis  of  the  mandible  by  the  mobilisa- 
tion of  a  bony  bridge  obtained  from  the  posterior 
fragment,  care  being  taken  to  preserve  all  the  periosteal 
attachments.  Unfortunately  he  has  not  been  able 
to  employ  his  method  upon  the  living  subject. 

Cavalie  (of  Bordeaux)  has  employed  a  somewhat 
specialised  technique  in  bone-grafting  {L'Odontologie, 
June  30th,  1916). 

According  to  whether  the  gap  is  more  or  less  than 
2  cm.,  he  cuts  from  one  or  both  fragments  a  bony 
strip,  the  length  of  which  is  greater  than  that  of  the 
space  to  be  bridged.  This  bony  strip  is  covered  by  its 
periosteum  and  by  connective  tissue ;    its  lower  face 


SURGICAL   TREATMENT  757 

is  covered  by  spongy  tissue.  It  is  either  pushed  or 
turned  backwards  to  the  breach.  From  the  author's 
description  it  seems  better  to  leave  a  peduncle  of  perios- 
teum. Where  two  grafts  are  employed,  they  are 
fastened  together  in  the  centre  of  the  fracture  site. 
The  grafts  are  kept  in  place  by  a  catgut  suture. 

Cavalie  does  not  give  a  detailed  description  of  his 
cases.  He  merely  states  that,  in  15  cases  out  of  21, 
the  grafts  either  united  or  were  in  process  of  union 
with  the  fragments. 

Independently  of  any  knowledge  of  Cavalie 's  re- 
searches, we  have  on  several  occasions  made  use  of 
fragments  detached  from  the  fractured  extremities. 
We  must  confess  that  our  results  were  not  entirely 
satisfactory.  The  a  priori  cause  lies  probably  in  the 
fact  that  the  graft  is  insufficient  to  replace  extensive 
loss  of  substance,  and  yet  it  is  just  this  class  of  case 
with  which  the  graft  is  required  to  deal. 

At  the  Interallied  Dental  Congress,  and  before  the 
Societe  de  Chirurgie,  Sebileau  gave  an  account  of 
eight  operations  with  bony  grafts  taken  from  the 
tibia.  In  only  three^  cases  has  a  sufficient  period 
elapsed  for  results  to  be  demonstrable.  Of  these, 
union  was  effected  in  one  case,  amelioration  in  the  two 
othera  (see  his  communication  to  the  Societe  de 
Chirurgie,  November  8th,  1916).  Interesting  obser- 
vations have  also  been  published  by  Pont. 

Delageniere  has  adopted  a  different  method.  His 
autografts  are  osteo-periosteal,  and  are  obtained  from 


758      FRACTURE  OF   THE  LOWER  JAW 

another  part  of  the  body.  His  observations  were 
described  before  the  Societe  de  Chirurgie,  May  3rd, 
1916. 

His  method  consists  in  taking  a  shaving  of  periosteum 
lined  with  more  or  less  bony  substance  from  the  tibia. 
The  method  has  been  employed  to  replace  loss  of 
substance  from  the : skull,  the  long  bones,  etc.,  and 
it  has  been  applied  to  two  cases  of  mandibular  pseudo- 
arthrosis. 

In  one  case  pseudo-arthrosis  was  due  to  loss  of  sub- 
stance from  the  body  of  the  jaw.  The  two  fragments 
were  maintained  in  good  position  by  means  of  a  little 
metal  plate  with  two  holes.  The  interval  of  15  mm. 
was  filled  by  an  osteo-periosteal  graft  from  the  tibia. 
In  spite  of  somewhat  profuse  suppuration  a  voluminous 
bony  callus  was  formed.  At  the  time  of  publication 
the  metal  plate  had  not  been  removed. 

The  second  case  presented  pseudo-arthrosis  of  the 
horizontal  branch,  with  trapezoid  loss  of  substance 
amounting  to  2  cm.  at  the  alveolar  border  and  3|^  cm. 
at  the  inferior  border.  An  aluminium  plate  with  two 
screws  at  the  posterior  end  and  one  at  the  anterior 
end  was  applied.  The  osteo-periosteal  graft  was  intro- 
duced under  the  plate  between  the  two  fragments. 
There  were  suppuration  and  expulsion  by  the  mouth 
of  the  bony  portion  of  the  graft.  The  author  states 
that  new  bone  seemed  to  form.^ 

1  Since  these  lines  were  written,  Delageniere  has  announced 
that  union  has  been  effected  in  both  his  cases  under  satisfactory 
conditions.  Other  successful  cases  of  his  were  described  |jy 
Lebedinsky  at  the  Interallied  Dental  Congress. 


SURGICAL  TREATMENT  759 

Our  own  researches  have  been  conducted  upon 
somewhat  different  lines. 

Our  fiist  endeavour  is  to  maintain  the  vitality  of 
the  graft,  for  it  is  certain  that  a.  bone  completely 
detached  from  its  connections  may  continue  to  live. 
With  this  object  in  view  we  have  thought  it  preferable 
to  perform  the  operation  in  two  parts,  with  a  long 
interval  between  them. 

The  first  part  of  the  operation  consists  in  the  removal 
of  a  fragment  of  bone,  generally  from  one  of  the 
patient's  ribs,  and  its  introduction,  with  the  minimum 
of  operative  manipulation,  under  the  integuments  of 
the  region  of  operation  in  the  vicinity  of  the  pseudo- 
arthrosis. Simple  puncture  with  the  bistoury  and 
separation  of  the  soft  parts  are  sufficient.  The  costal 
fragment  is  then  slipped  into  the  opening,  whioh  is 
closed  with  a  stitch.  The  manoeuvre  is  one  of  extreme 
simplicity.  The  graft  is  always  tolerated,  but  our 
investigations  do  not  permit  us  to  conclude  that  it 
lives  a  normal  life.  In  some  of  our.  cases  a  small 
secondary  fistula,  corresponding  to  a  centre  of  necrosis 
of  the  graft,  appeared  after  a  few  days.  But  this 
centre  of  necrosis  was  limited  and  was  never  accom- 
panied by  elimination.  The  greater  number  of  cases 
healed  by  first  intention. 

As  soon  as  the  graft  has,  presumably,  acquired  means 
of  nutrition,  which  is  not  until  two  or  three  months 
have  elapsed,  it  is  put  into  place  by  operation.  In 
moving  the  fragment,  its  new  vascular  connections  are 
interfered  with  as  little  as  possible. 


;<)()      FRACTURE   OF   THE   LOWER  JAW 

In  only  three  cases  were  we  able  to  accomplish  the 
second  part  of  the  operation  in  a  satisfactory  manner. 
In  the  first  case  there  was  loose  pseudo-arthrosis  with 
loss  of  the  entire  left  portion  of  the  mandible  including 
the  ramus.     With  the  object  of  achieving  a  physio- 


Fio.  97. — Left  lateral  fracture  with  largo  loss  of  substance. 
Pseudo-arthrosis  in  spite  of  prolonged  imraobiiisation.  This  case 
has  been  treated  by  means  of  a  bone  graft.     Result  as  yet  uncertain. 


logical  substitute  for  the  temporo-mandibular  joint, 
we  grafted  a  bony  fragment  froir.  the  ribs  together 
with  the  adjacent  costal  cartilage.  The  bony  portion 
of  the  graft  was  secured  to  the  extremity  of  the  mandi- 
bular fragment  by  two  screws.  The  result  was  excel- 
lent in  the  sense  that  union  by  first  intention  was 


SURGICAL  TREATMENT  761 

obtained.  But  to-day,  eight  months  after  the  second 
operation,  the  graft  is  absolutely  mobile  on  the 
mandible.  There  is  no  visible  sign  of  a  callus,  and  the 
functional  gain  is  nil. 

In  a  second  case  we  adopted  similar  measures  for  a 
loss  of  substance  of  the  left  ramus  measuring  about 
3  cm.,  which  had  been  unsuccessfully  treated  for 
several  months  by  means  of  mechanisms.  We  first 
introduced  under  the  skin  a  costal  fragment  measuring 
about  5  cm.  taken  from  the  patient.  The  graft  was 
tolerated.  At  the  end  of  two  months  we  moved 
the  costal  fragment  and  shaped  each  end  to  a  point. 
These-  were  inserted  into  two  cavities  cut  in  the 
mandibular  fragments.  The  retention  of  the  graft 
by  this  means  was  satisfactory.  But  the  operation 
is  of  too  recent  a  date  for  the  definitive  results  to  be 
apparent. 

The  third  case  is  more  recent  still.  A  large  part  of 
the  dental  arch  was  missing.  The  graft  was  fixed 
by  means  of  a  metal  plate  screwed  to  the  fragments 
in  another  place.  ^ 

In  accordance  with  the  suggestion  of  M.  Lequeux, 
we  have  employed  as  grafts  bones  from  a  new-born 
infant.  Through  the  kindness  of  the  staff  of  La 
Maternite,  Marseilles,  we  were  able  to  obtain  the  body 
of  a  still-born  infant  under  suitable  conditions.  We 
removed  the  principal  bones  of  the  skeleton  and  pre- 

1  These  operations  are  now  no  longer  recent.  In  no  case  was 
union  obtained. 


762     FRACTURE   OF   THE  LOWER  JAW 

served  them  in  vaseline  in  a  refrigerator  at  +4°.  We 
found  that  fragments  of  these  bones  were  perfectly 
tolerated  in  the  tissues  of  patients  not  wounded  in 
the  face.  We  then  decided  to  use  them  as  true  bony 
grafts  in  two  cases  of  mandibular  fracture.  We  fol- 
lowed the  method  of  operation  in  two  parts.  The 
fragments  were  first  introduced  under  the  skin,  where 
they  were  tolerated  without  ill  effects.  The  one  frag- 
ment consisted  of  the  inferior  extremity  of  the  femur 
wjth  the  cartilaginous  nucleus  of  growth,  the  other 
of  the  superior  extremity  of  the  humerus  in  the  same 
condition.  The  future  will  show  the  value  of  these 
experiments. 

To  sum  up  :  we  believe  we  are  justified  in  concluding 
that,  at  the  present  moment,  the  results  of  bone- 
grafting  in  mandibular  pseudo-arthrosis  are  not  as  yet 
demonstrated.  As  Sebileau  has  said,  they  are  encour- 
aging— no  more.  It  is  to  be  expected,  however,  that 
the  efforts  made  in  many  directions  to  obtain  the  cure 
of  pseudo-arthrosis  by  bony  transplantation  will 
result  in  an  improvement  of  general  knowledge  which 
must  react  to  the  benefit  of  mandibular  lesion. 


CHAPTER    VII 

ASSESSMENT  OF   THE  DISABLEMENTS  CONSEQUENT  UPON 
FRACTUBE    OP   THE   MANDIBLE 

In  an  article  which  appeared  in  the  Archives  de 
medecine  et  de  pharmacie  militaires  (April  1916),  we 
showed  what  we  believe  to  be  the  best  method  of 
assessing  incapacity  arising  out  of  mandibular  fracture. 
Briefly,  compensation  for  disablement  comes  under 
five  headings  : 

1.  Discharge  with  pension. 

2.  Definitive  discharge  No.  1  with  or  without  a 
grant. 

3.  TemporarjT^  discharge  with  or  without  a  grant. 

4.  Return  to  an  auxiliary  branch  of  the  service. 

5.  Return  to  active  service. 

The  difference  between  definitive  retirement  No.  1 
and  temporary  retirement  No.  3  is  appreciable  only  to 
the  patient.  In  the  case  of  the  first,  he  can  never 
again  be  taken  for  the  army,  his  dismissal  being 
definitive.  In  the  case  of  the  second,  the  patient's 
condition  is  assumed  to  be  amenable  to  a  degree  of 
amelioration,  which  will  render  him  liable  at  some 
future  time  for  auxiliary  or  even  for  active  service. 
Apart  from   incurability,    a  retirement  pension  pre- 

763 


764     FRACTURE  OF   THE  LOWER  JAW 

supposes  the  existence  of  incapacity  assessed  at  at 
least  60  per  cent.  Except  where  there  is  extensive 
loss  of  substance  of  the  soft  parts,  fracture  of  the  man- 
dible, even  with  loss  of  bony  substance,  is  not  associated 
with  so  high  a  degree  of  functional  incapacity.  It 
follows  that  discharge  with  pension  is  granted  only 
very  occasionally.  Nevertheless,  the  inclusion  of  this 
class  in  the  scale  of  disabilities  provides  for  certain 
isolated  cases. 

To  the  best  of  our  knowledge,  the  degree  of  disable- 
ment which  renders  a  man  liable  to  be  returned  for 
auxiliary  service  is  not  fixed.  There  is  a  tendency  to 
regard  as  eligible  a  maximum  incapacity  of  10  to  20 
per  cent. 

With  regard  to  grants,  the  military  regulations 
have  established  a  certain  fixed  scale  which  does  not 
exist  under  civilian  conditions.  Disablements  are 
calculated  in  tens  per  cent.,  and  there  is  no  recognition 
of  intermediary  figures. 

We  shall  successively  consider  : 

1.  Loss  of  teeth,  generally  complicated  by  more  or 
less  important  fracture  of  the  alveolar  border. 

2.  Fracture  of  the  mandible,  with  its  principal 
terminations,  thus  : 

(a)  Union  in  good  position  with  preservation  of 
occlusion. 

(6)  Union  in  malposition, 
(c)  Pseudo-arthrosis. 

3.  Closure  of  the  jaws,  so  frequently  associated  with 
wounds  of  the  face. 


ASSESSMENT  OF  DISABLEMENTS     765 

T.  Loss  OF  Teeth,  Complicated  by  Fracture  of 
THE  Alveolar  Border  but  without  Complete 
Fracture 

Loss  of  teeth  is  remedied  by  the  employment  of 
various  prosthetic  mechanisms,  of  which  the  best  is 
the  bridge.  This  is  a  fixed  apparatus,  the  essential 
feature  of  which  is  a  platform  corresponding  to  the 
missing  teeth  and  attached  to  at  least  two  pillars. 
The  pillars  are  metal  caps,  screw-crowns,  etc.,  by  which 
the  teeth  at  each  extremity  of  the  dental  breach  are 
covered.  This  apparatus  is  cemented  to  the  teeth, 
and  it  affords  the  nearest  approach  to  the  normal 
state.  It  is  durable,  and  it  completely  re-establishes 
function. 

Unfortunately  the  employment  of  the  bridge  is 
advisable  only  where  the  loss  of  teeth  is  minimal 
(four  at  the  most).  But  wherever  its  employment  is 
permissible  we  do  not  think  that  there  are  justifiable 
grounds  for  indemnity. 

Larger  gaps  are  filled  by  means  of  removable 
mechanisms,  the  base  of  which  is  composed  of  vul- 
canised india-rubber.  These  are  fitted  with  good 
quality  artificial  teeth,  and  their  attachment  is  by 
hooks  of  German  silver.  A  partial  apparatus  of  this 
kind,  even  of  considerable  size,  perfectly  re-establishes 
function  so  long  as  the  remaining  teeth  assure  a  good 
anchorage ;  two  sound  teeth  in  each  fragment,  for 
example,  a  premolar  on  one  side  and  molar  on  the 
other,  are  ample  for  the  purpose  providing  they  are 


766      FRACTURE  OF  THE  LOWER  JAW 

sufficiently  apart.     Here  again  we  cannot  admit  any 
functional  incapacity. 

Where  a  complete  apparatus  is  required,  a  judicial 
estimation  of  incapacity  is  dependent  upon  two  entirely 
different  factors.  In  the  majority  of  cases  these 
mechanisms  are  well  tolerated  and  permit  of  almost 
normal  mastication.  But  there  are  a  certain  number 
of  patients  who,  through  lack  of  perseverance,  are 
unable  to  accustom  themselves  to  the  use  of  the 
apparatus.  On  the  other  hand,  it  must  be  remembered 
that  the  loss  of  all  the  teeth  is  not  entirely  the  result 
of  the  traumatism.  As  a  general  rule  the  dental 
condition  previous  to  injury  was  precarious,  and  for 
this  the  State  cannot  be  responsible.  We  think  that, 
on  the  grounds  of  intolerance,  an  indemnity  is  justified, 
but  on  account  of  loss  of  teeth  we  think  that  it  should 
not  be  high.  An  average  of  10  per  cent,  seems  to  us 
to  be  fair. 

It  is  understood  that  the  State  bears  the  cost  of 
replacing  and  repairing  these  mechanisms.  For  they 
are  liable  to  wear  out.  The  alveolar  processes  undergo 
involution,  and  an  apparatus  which  was  perfect  at 
the  time  of  its  application  may,  after  a  certain  time, 
become  defective  or  break.  The  State  might  reason- 
ably entrust  this  matter  at  a  uniform  tariff  either 
to  stomatologists  appointed  by  the  State,  to  the 
stomatological  department  of  hospitals,  or  to  dental 
schools. 


ASSESSMENT  OF  DISABLEMENTS     767 

II.     Fractures 

These  fractures  terminate  in  various  ways,  all  of 
which  do  not  present  disturbance  of  function  in  the 
same  degree. 

{a)  Fracture  with  union  in  good  position. — This  does 
not  require  an  indemnity,  but  the  State  undertakes  to 
replace  the  teeth  destroyed  by  the  traumatism. 

(6)  Fracture  with  union  in  malposition. — ^Malocclu- 
sion should  not  be  taken  into  account  unless  it  affects 
at  least  half  of  the  dental  arch  and  is  of  such  a  nature 
that,  whatever  the  position  of  the  mandible,  the  patient 
is  always  unable  to  use  the  teeth  of  both  sides  simul- 
taneously. This  state  is  realised  when  deviation 
of  half  of  the  arch  is  so  pronounced  that  its  ensemble 
passes  either  within  or  without  the  corresponding 
teeth  of  the  upper  jaw.  In  such  a  case  as  this  we 
estimate  the  incapacity  at  20  per  cent. 

The  infirmity  is  necessarily  greater  where  the  man- 
dible is  united  but  contracted,  and  closes  entirely 
within  the  superior  maxilla,  the  inferior  teeth  present- 
ing no  point  of  contact  with  the  corresponding  superior 
teeth.  It  is  true  that  an  attempt  may  be  made  to 
remedy  this  deformity  by  an  apparatus  attached  in 
front  of  the  remaining  inferior  teeth  ;  a  supplementary 
dental  arch,  repeating  the  main  arch  and  articulating 
with  the  superior  teeth.  It  is  obvious  that  the 
anchorage  of  an  apparatus  such  as  this  will  last  only 
as  long  as  the  teeth  are  sound.  Its  stability  and  conse- 
quent  utility    disappear   with   them.     In   any   case, 


7G8      FRACTURE   OF   THE   LOWER  JAW 

an  apparatus  of  this  kind  is  able  to  restore  function 
only  very  imperfectly.  Under  such  circumstances 
the  indemnity  should  not  be  less  than  30  per  cent. 

(c)  Fracture  ivithout  union  ;  pseudo-arthrosis. — Func- 
tional troubles  arising  from  non-consolidation  of  frac- 
ture of  the  mandible  are  modified  by  the  seat  of  fracture 
on  the  one  hand  and  on  the  other  by  the  degree  of 
laxity  of  the  pseudo-arthrosis — in  other  words,  by 
the  amount  of  substance  lost. 

A   very  loose   pseudo-arthrosis  with   large  loss   of 
substance  (a  finger-width  and  over)  should  be  largely 
indemnified.     Wherever  situated,  it    is   accompanied 
by  almost  total  suppression  of  function,  and  we  estimate 
the  indemnity  at  40  per  cent.     We  are  aware  that 
prosthetic  apparatuses  may  be  employed  in  cases  of 
this  class,  but,  owing  to  the  extreme  mobility  of  the 
fragments,   such  mechanisms  are   of  minimal  value. 
Their    application    does    not    appreciably    lower    the 
coefficient  of   incapacity,  especially  as  their  employ- 
ment is  dependent  in  part  upon  the  dental  conditions. 
As  soon  as  the  remaining  teeth  disappear,  the  func- 
tional value  of  the  mechanism  is  reduced  in  a  notable 
proportion    which    may  fall  to    zero.     There    is    one 
mechanism    only    which    is    able    appreciably   to    re- 
establish function,  and  that  is  the  bridge,  extending  as 
it  does  between  the  fragments  and,  by  the  agency  of 
the  teeth  which  serve  as  pillars,  giving  them  solidarity. 
It  is  evident  that  such  an  apparatus  is  not  applicable 
except  where  a  sufficient  number  of  teeth  suitable  for 
anchorage  are  present.      In  our  view,  two  teeth  on 


ASSESSMENT  OF  DISABLEMENTS      769 

each  side  of  the  gap  is  the  minimum.  In  such  a  case 
the  functional  incapacity  equals  20  per  cent.  But  in 
view  of  the  fact  that  the  pillars  of  the  bridge  may  fail 
and  the  patient  be  compelled  to  resort  to  a  removable 
mechanism,  we  feel  that  the  functional  incapacity 
should  not  be  estimated  at  less  than  40  per  cent. 

Where  the  pseudo-arthrosis  is  less  lax  (a  finger- 
width or  two  teeth  and  less),  patients  may  under 
certain  conditions  almost  entirely  recover  their  func- 
tional capacity,  though  under  others  it  remains  con- 
siderably impaired.  Here  the  coefficient  of  incapacity 
is  indeterminate  and  ranges  from  10  to  40  per  cent. 

Contrary  to  what  one  would  suppose,  the  nearer 
the  pseudo-arthrosis  is  situated  to  the  temporo- 
mandibular joint,  the  less  as  a  rule  is  the  derangement 
of  function.  We  were  able  to  send  a  man  back  to 
the  front  who  had  lost  a  condyle  with  its  neck  as  the 
result  of  fracture  by  a  bullet.  In  these  lesions,  and 
in  all  those  affecting  the  ramus  as  far  down  as  the 
angle,  there  is  no  derangement  of  occlusion,  and  the 
movements  of  the  mandible  are  unimpaired. 

Where  the  pseudo-arthrosis  is  rather  more  forward 
and  is  situated  in  the  molar  region,  it  is  almost  in- 
variably accompanied  by  deviation  of  the  fragments, 
by  which  the  articulation  of  the  dental  arches  is 
destroyed.  Here  it  is  necessary  for  the  patient  to 
wear  a  guiding  mechanism  which  will  correct  the 
deviation  and  restore  normal  occlusion.  This  is 
usually  an  easy  matter,  provided  always  that  the 
patient  possesses  a  certain  number  of  sound  teeth. 


770     FRACTURE  OF   THE   LOWER  JAW 

On  the  other  hand,  it  must  be  admitted  that  even 
under  these  circumstances  mastication  is  very  imper- 
fect. In  consequence  of  the  fracture  of  the  mandible, 
which  normally  forms  the  rigid  lever  to  which  their 
action  is  directed,  the  power  of  the  masticatory  musclevs 
is  very  much  reduced.  Such  patients  are  practically 
incapable  of  chewing  solid  food  and  it  is  easy  to  foresee 
the  troublesome  sequelrc  inevitable  to  imperfect 
mastication.  In  such  circumstances,  to  estimate 
functional  incapacity  at  20  per  cent,  does  not  seem 
excessive.  Where,  however,  the  pseudo-arthrosis  is 
narrower  and  tends  to  act  as  a  fibrous  callus,  the 
indemnity  may  be  reduced  to  10  per  cent.  It  is  certain 
that  the  narrower  the  pseudo-arthrosis,  the  easier  it  is 
to  provide  a  suitable  mechanism,  whether  fixed  or 
removable,  and  the  more  efficient  the  services  which 
it  is  able  to  render.  The  question  is  one  of  degree,  and 
can  be  decided  only  by  careful  examination  of  each 
patient. 

It  is  in  pseudo-arthrosis  in  the  vicinity  of  the 
symphysis  that  prosthetic  mechanisms  attain  their 
maximum  of  usefulness,  for  their  chief  function  is  to 
maintain  normal  occlusion  by  separating  the  frag- 
ments, which  have  an  inherent  tendency  to  approach 
one  another.  Experience  shows  that  these  apparatuses, 
having  approximately  equal  points  of  support,  provided 
in  each  case  by  half  the  dental  arch  and  acted  on  by 
muscular  synergic  forces  which  are  approximately 
equal,  are  more  efficacious  than  lateral  mechanisms. 
The  bridge  is  particularly  indicated  in  these  pseudo- 


ASSESSMENT  OF  DISABLEMENTS     771 

arthroses  with  slight  loss  of  substance,  provided  always 
that  the  points  of  anchorage  are  solid  in  character 
and  sufficient  in  number  (four  teeth  is  the  minimum). 
Thus,  in  our  view,  median  and  paramedian  pseudo- 
arthroses are  those  which,  functionally  speaking,  are 
the  least  discouraging.  An  indemnity  of  10  to  20 
per  cent,  seems  just.  As  we  have  shown  in  an  earlier 
chapter,  these  cases  are  the  least  frequent.* 

III.     Closure  OF  THE  Jaws 

Cases  of  mandibular  constriction  should  be  recom- 
mended for  indemnity  only  under  extreme  reservation. 
Nevertheless  it  is  regrettable,  to  say  the  least,  that 
these  cases  should  become  permanent  chronics  in  our 
special  or  general  hospitals. 

We  have  already  had  occasion  to  describe  our  experi- 
ences in  this  direction,  which  may  be  briefly  sum- 
marised as  follows  : 

It  is  certain  that  a  proportion  of  these  cases  are 
those  of  pure  simulation  or  of  gross  exaggeration. 
Proof  is  usually  easy  to  obtain. 

But  we  believe  that  the  majority  of  closures  are 
due   to   a   simple   muscular   contraction.     These   are 

1  As  we  have  shown,  we  do  not  beUeve  that  mandibular  pseudo- 
arthrosis should  be  included  among  the  cases  eligible  for  pension 
with  discharge.     But  the  following  must  be  regarded  as  incurable  : 

1.  Pseudo-arthrosis  resulting  from  very  extensive  loss  of  bony 
substance. 

2.  Pseudo-arthrosis  which,  having  been  operated  upon  either  by 
osteo-synthesis  or  by  grafting,  has  failed  to  unite. 

These  are  the  only  classes  of  case  where  fracture  of  the  mandible 
might  possibly  be  compensated  by  discharge  with  pensioa. 


772      FRACTURE  OF   THE  LOWER  JAW 

oases  of  hypertonicity  similar  to  those  observed  by 
neurologists.  By  employing  an  automatic  mouth- 
opener  iouvre-houche)  and  exercising  moderate  pressure, 
the  resistance  is  found  gradually  to  diminish  in  the 
same  way  that  a  tired  muscle  "  gives,"  and  the  mouth 
may  eventually  be  opened  with  ease.  These  patients 
should  receive  regular  treatment  continued  over  several 
weeks,  and  there  is  no  question  of  indemnity. 

Last  of  all,  there  are  closures  due  to  cicatrices,  to 
muscular  sclerosis,  or  to  bony  fusion.  The  first  of 
these  is  undoubtedly  amenable  to  surgical  interven- 
tion. So  also  is  the  third,  but  it  is  rare.  Out  of  more 
than  150  constructions  arising  from  wounds  of  war, 
among  which  temporo-maxillary  wounds  were  not 
infrequent,  we  have  never  seen  a  case.  Fibrous 
retractions  are  very  obstinate,  and  might  in  some 
cases  provide  grounds  for  indemnity.  This  is  a  matter 
which  can  only  be  decided,  however,  after  surgical 
intervention.  It  is  incontestable  that  section  of  the 
tendon  of  the  temporal  or  operation  of  the  Le  Dentu 
is  sometimes  attended  by  good  results.  But  this  is 
by  no  means  invariably  the  case,  and  some  of  our 
patients  have  relapsed  in  spite  of  every  effort. 

That  absolute  occlusion  constitutes  a  serious  con- 
dition seems  to  us  incontestable,  and  an  indemnity  of 
40  per  cent,  does  not  seem  to  us  excessive.  Such  an 
instance  has  never  come  under  our  notice,  and  it  must 
in  any  case  be  very  exceptional. 

Where  the  mouth  may  be  opened  as  much  as  2  cm. 
alimentation  is  perfectly  possible. 


ASSESSMENT  OF  DISABLEMENTS     773 

In  the  very  rare  cases  which  occupy  a  place  between 
absolute  occlusion  and  an  opening  of  2  cm.,  we  are  of 
opinion  that  an  indemnity  of  10  to  20  per  cent,  should 
suffice.  It  must  be  repeated  that  such  cases  are  quite 
exceptional. 

Finally,  we  desire  to  emphasise  the  fact  that  our 
personal  experience  does  not  countenance  definitive 
conclusions  upon  all  these  points.  This  brief  sum- 
mary does  not  pretend  to  do  more  than  furnish  a 
classification  of  the  different  types  of  disablement, 
such  as  may  be  employed  as  a  basis  of  discussion. 


SECTION  III 

FRACTURES  OF  THE 
ORBIT 


FRACTURES  OF   THE    ORBIT 

AND 

INJURIES   TO   THE   EYE    IN    WAR 


CHAPTER  I 
HISTORICAL 

The  history  of  fractures  of  the  orbit  by  projectiles 
of  war  obviously  cannot  be  traced  farther  back  than 
the  use  of  gunpowder,  but  in  the  old  writers  are  found 
interesting  notes  upon  orbital  traumatism  in  com- 
batants of  all  ages. 

Homer,  in  the  Fourth  Book  of  the  Iliad,  tells  us 
that  "  Penelius  struck  Ilioneus  beneath  the  eyebrow 
towards  the  back  of  the  eye,  of  which  the  pupil  was 
torn  away ;  and  the  spear,  piercing  the  eye,  came  out 
at  the  back  of  the  head;  and.  Ilioneus,  his  hands 
stretched  forth,  fell." 

Does  this  not  clearly  indicate  an  orbital  fracture 
with  cerebral  lesion  ?  ...  In  the  ancient  books  many 
similar  indications  are  to  be  found. 

It  is  not  only  among  the  poets  that  we  can  find 
much  to  interest  us  in  this  subject.  Hippocrates 
gives  wise  counsel  when  he  writes  :  "  If  it  be  needful 
to  attempt  the  extraction  of  a  foreign  body  deeply 
forced  into  the  orbit  through  integuments  and  orbital 
muscles,  only  light  traction  should  be  used,  and  if 
the  difficulties  are  great,  it  will  be  better  to  temporise." 
(Hippocrates,  De  morb.  vulgar.,  Lib.  V,  Chap.  XXI.) 

When,  in  the  wars  of  the  middle  ages,  firearms 
appeared,  injuries  of  the  face  and  cranium  multiplied. 

777 


778  FRACTURES  OF  THE  ORBIT 

In  the  writings  of  Italian  surgeons  of  the  period 
mention  is  made,  in  very  imperfect  manner,  of  frac- 
tures of  the  orbit,  treated  by  the  application  of  boiling 
oil. 

It  is  not  until  we  come  to  the  sixteenth  century,  in 
Albucasis,  Fabricius  of  AcQUAPENDENTE,  and  espe- 
cially Ambrose  Pare,  that  we  find  detailed  descrip- 
tions of  orbital  lesions,  accounts  of  the  tolerance, 
sometimes  very  great,  of  these  cavities  with  respect 
to  projectiles,  and  of  the  necessity,  in  spite  of  every- 
thing, of  hastening  their  extraction  for  fear  of  serious 
complications.  The  interference  advocated  by  these 
surgeons  was  attempted  by  them  whenever  occasion 
presented ;  hence  they  designed  a  varied  series  of 
instruments,  and  the  bullet  extractors  of  Ravaton, 
Peret  and  Brambilla  remain  as  types  of  these 
instruments  in  medical  literature. 

In  Percy's  Manuel  de  Chirurgie  d'armee  (1792),  a 
chapter  headed  "  Wounds  of  the  face,  with  foreign 
bodies,"  instructs  us  as  to  the  state  of  knowledge  of 
lesions  of  the  orbit  and  of  the  eyes  at  this  time ;  more 
particularly  concerning  affections  of  the  walls  of  the 
orbit,  with  their  effects  on  the  neighbouring  sinuses, 
frontal  and  maxillary.  Collignon  and  Schmecker 
have  found  pieces  of  iron  and  whole  bullets  which 
have  remained  in  situ  for  many  years  and  been  finally 
eliminated  by  way  of  the  nose.  Curious  cases  of  this 
kind  are  also  to  be  found  in  the  Ephemerides. 

According  to  Percy,  not  all  the  cases  with  a  bullet 
in  the  eye  were  as  fortunate  as  the  one  in  which 
CoviLLARD  replaced  the  eyeball  in  the  orbit,  from 
which  a  foreign  body  had  displaced  it.  "  It  is  all 
over,"'  said  he,  "  with  that  organ,  no  matter  how 
slightly  a  projectile  has  touched  it.  If  it  happened 
to  be  lodged  in  the  fat  at  the  back  of  the  orbit  we 
used  one  blade  of  our  forceps  and  replaced  the  eye 
by  CoviLLARD "s  method." 

To  show  the  gravity  of  such  injuries,  Percy  quotes 
two  cases,  one  which  came  under  his  own  observation, 
the  other  noted  by  Stalpart  van  der  Wiel,  of  large 


HISTORICAL  779 

intra -orbital  foreign  bodies  (points  of  swords  or  foils), 
which  caused  fractures  of  the  roof  of  the  orbit  and  in 
which  extraction  was  followed  by  cerebral  symptoms 
and  rapid  death. 

In  his  Manuel  de  Clinique  chirurgicale,  published  in 
1832,  Larrey  devotes  a  chapter  to  wounds  of  the 
face  by  projectiles  of  war,  and  is  the  first  to  set  forth 
original  views  on  the  mechanism,  prognosis  and 
treatment  of  these  injuries. 

The  great  surgeon  of  the  First  Empire,  from  his 
personal  observation,  cited  cases  of  rapid  recovery  from 
orbital  fractures,  even  when  they  presented  a  certain 
degree  of  gravity,  and  he  remarks  that  the  younger 
the  subject  the  quicker  the  recovery. 

On  the  other  hand,  he  quotes  two  cases  with  cerebral 
complications  and  ultimate  death  from  meningitis. 

In  the  necropsies  of  these  two  cases,  Larrey  notes 
that  as  a  sequence  of  the  perforation  of  the  orbit  by  the 
projectiles  the  bones  had  proliferated  and  so  consider- 
ably reduced  the  volume  of  the  cavities.  He  sees  in 
this  Nature's  protective  efforts  to  repair  the  damage 
caused  by  the  shot.  Intra-orbital  foreign  bodies,  he 
adds,  are  sometimes  tolerated  for  very  long  periods, 
and  then  evacuation  takes  place,  sometimes  by  the 
mouth,  sometimes  by  the  nasal  fossae. 

Baudens,  in  1836,  and  Vallee,  in  1838,  collect  the 
cases  previously  published,-  the  first  in  the  form  of 
clinical  lectures,  the  second  in  his  inaugural  thesis. 
We  do  not,  however,  find  in  these  works  anything  to 
merit  prolonged  consideration. 

More  important  and  instructive  is  the  article  pub- 
lished in  1851  by  Bertherand  entitled  "  Des  plaies 
d "amies  a  feu  de  Torbite  "  (Gunshot  wounds  of  the 
orbit).  "  If  a  shot,"  he  writes,  "  strikes  the  eye,  the 
spherical  elastic  surface  which  it  presents  may  cause 
the  ball  to  deviate.;  or  it  may  happen  that  the  eye, 
without  being  ruptured,  may  be  forced  outside  the 
cavity.  Deflected  by  the  globe,  the  projectile  may 
retain  sufficient  force  to  fracture  the  bony  walls  of 
the  orbit  and    lodge  in    adjoining    cavities   (sinuses, 


780  FRACTURES  OF  THE  ORBIT 

nasal  fossae,  cranium).  The  resistance  of  the  bones 
which  form  the  anterior  margin  of  the  orbit  and  the 
convexity  of  the  superciliary  arch  explain  the  devia- 
tion of  gun-shots  and  the  comminuted  fractures  which 
result  when  they  strike  these  parts.  It  is  superfluous 
to  emphasise  the  gravity  of  the  injuries  due  to  the 
frequent  penetration  of  projectiles  into  the  cranial 
cavity  "  {Annates  d'Oculistique,  1851,  p.  127). 

DuPUYTREN,  and  after  him  Desmarres,  give  a 
classification  of  orbitral  fractures  (1854).  They  dis- 
tinguish :  1st.  Fracture  of  the  margin  (Dupuytren 
and  Baudens)  ;  2nd.  Fracture  of  the  walls  (Dupuy- 
tren and  Hennen),  extending  sometimes  to  the  apex 
of  the  orbit ;  3rd.  Fractures  of  the  apex,  almost 
always  complicated  by  visual  disturbances,  because  of 
injury  to  the  optic  nerve;  4th.  Fractures  by  "contre- 
coup,"  from  traumatism  of  the  cranial  bones  or  of  the 
bones  of  the  face. 

A  similar  classification,  as  regards  intra-orbital 
foreign  bodies,  is  given  by  Demarquay  in  his  "  Memoire 
sur  les  corps  etrangers  arretes  dans  I'orbite  "  (An  account 
of  cases  of  foreign  bodies  lodged  in  the  orbit)  {Union 
medicale,  2nd  series.  Vol.  IV,  1859).  Demarquay, 
making  use  of  cases  reported  by  Demours,  Desmarres, 
G ENSOUL,  Waldon,  Cunier,  Joeger,  divides  them 
into  :  1st,  projectiles  propelled  by  gunpowder — shot, 
particles  of  lead,  other  fragments ;  2nd,  portions  of 
perforating  instruments ;  3rd,  fragments  of  glass ; 
4th.  pieces  of  wood.  He  describes  with  precision  the 
concomitant  symptoms  :  sub-conjunctival  ecchymosis, 
haemorrhage  from  nose  and  mouth,  and  insists  upon 
the  exophthalmos  produced  by  a  collection  of  blood 
or  pus.  Orbital  inflammations  are  not  frequent  in 
gunshot  wounds,  he  says,  because  of  the  relative 
asepsis  due  to  the  heating  of  the  foreign  body.  We 
should  certainly  emphasise  the  correctness  of  this 
remark;  orbital  abscess  following  gunshot  injuries 
has  become  more  and  more  infrequent  with  the  im- 
provements in  modern  ballistics  and  the  great  initial 
velocity   of   projectiles.     Demarquay   further   draws 


HISTORICAL  781 

our  attention  to  the  cerebral  injuries  which  may 
remain  long  in  a  latent  condition  and  suddenly  cause 
the  death  of  the  patient  from  cerebral  abscess. 

Although  Percy  advises  enucleation  of  the  eyeball 
to  facilitate  the  extraction  of  the  offending  foreign 
body,  DemarquAy,  and  with  him  Warlomont  and 
Testelin,  find  this  procedure  too  energetic,  and  very 
prudently  recommend  keeping  the  eye  so  long  as 
vision  remains. 

In  the  following  years  there  is  but  little  mention 
of  fractures  of  the  orbit.  However,  in  1862  Deval, 
Dickson,  and  in  1865  Mackenzie,  mention  some 
observations  on  foreign  bodies  tolerated  during  long 
periods  (from  three  months  to  seventeen  years).  Later 
comes  Berlin,  who,  in  an  essay  well  provided  with 
references  to  authorities,  clearly  sets  forth  the  matter. 

From  this  work  we  extract  the  details  which  appear 
to  us  of  importance.  Should  the  projectile,  says  the 
writer,  strike  the  temporal  region  obliquely  the  eye 
may  be  torn  away.  If  it  penetrate  horizontally, 
traversing  both  orbits,  section  of  both  optic  nerves 
follows  (Thompson's  case).  Injuries  of  the  lower  wall, 
rarer  than  the  others,  smash  up  the  orbital  floor  and 
the  maxillary  sinus.  In  some  cases  the  projectile 
exhausts  its  penetrative  power  on  the  bones  of  the 
face  and  comes  to  rest  against  the  roof  of  the  orbit. 

In  fractures  of  the  superior  wall  there  is  often  an 
accompanying  cerebral  lesion.  Recovery  is  frequently 
due  to  the  facility  with  which  the  wound  gets  rid  of 
its  discharges,  if  the  orbital  margin  is  involved  in  the 
loss  of  substance  (16  cases  out  of  19).  In  fractures 
of  the  vault  alone  prognosis  is  graver  (41  deaths  in 
55  cases).  Frequently  death  is  sudden  from  haemor- 
rhage ;  or,  on  the  other  hand,  delayed,  from  encephalo- 
meningitis.  Diagnosis  of  the  seat  of  fracture  is 
therefore  of  great  importance,  and  Berlin  advises, 
what  would  be  wrong  otherwise,  exploration  of  the 
injury  by  means  of  a  probe.  He  enlarges  next  on 
fractures  of  the  optic  foramen  with  secondary  lesions 
of  the  nerve,   due  either  to   compression  or  to   the 


782  FRACTURES  OF  THE  ORBIT 

tearing  of  the  nerve -elements,  brought  about  by 
splinters  or  by  effusion  of  blood  into  the  sheaths.  He 
describes  at  length  the  ophthalmoscopic  appearances 
in  those  disorders  which  lead  to  white  atrophy.  As 
to  the  treatment  of  orbital  fractures,  Berlin  recom- 
mends the  removal  of  the  bony  fragments  of  the 
vault  and  the  establishment  of  as  perfect  a  system  of 
drainage  as  possible,  and  advises  recourse  to  enucleation 
only  when  vision  is  irremediably  compromised. 

Manz  (1867),  ScHABERS  (1872),  and  Legouest  (1873) 
confirm  the  facts  demonstrated  by  Berlin. 

According  to  Galezowski  (1875),  fractures  of  the 
orbital  margin  are  not  very  frequent.  Most  often 
mentioned  are  fractures  of  the  internal  angle,  particu- 
larly of  the  lacrymal  bone,  and  fractures  at  the  apex 
with  damage  to  the  optic  nerve.  He  quotes  the  classic 
case  of  Nelaton  (punctured  wound  with  umbrella, 
fracturing  the  roof)  and  that  of  Borsa  (foreign  body 
in  the  orbit  tolerated  twenty-four  years,  extracted 
with  success). 

De  Wecker  and  Landolt  {Treatise  on  Diseases  of 
the  Eyes,  Vol.  IV,  p.  784,  1889)  divide  fractures  of  the 
orbit  into  direct  and  indirect,  the  first  provoking 
exophthalmos,  the  projection  of  the  eye  forwards,  and 
actual  dislocation.  They  describe  minutely  the  affec- 
tions of  the  different  walls  and  conclude  by  condemn- 
ing probing  of  the  wound  owing  to  fear  of. introducing 
infectious  germs  from  the  orbital  cavity  into  the 
cranium. 

They  emphasise  the  fact  that  the  absence  of  every 
symptom  on  the  side  of  the  general  condition,  and  of 
the  cerebro -spinal  axis  in  particular,  does  not  imply 
a  benign  injury,  for  cerebral  affections,  often  latent, 
may  blaze  out  suddenly  and  lead  to  a  fatal  issue  in  a 
few  hours. 

Delorme,  in  his  very  remarkable  Traite  pratique  de 
Chirurgie  d'armee  (1890),  also  reviews  the  various  forms 
which  have  been  discovered  by  clinical  observation ; 
his  chapter  is  an  accurate  resume  of  the  knowledge 
available  at  that  date. 


HISTORICAL  ^  783 

We  are  indebted  for  information,  unpublished  from 
the  point  of  view  of  statistics,  to  Chauvel  (article 
"  Orbite,"  Dictionnaire  des  Sciences  medicates)  and  to 
Chauvel  and  Nimier  in  their  work  on  Military  Surgery 
published  in  1890.  These  authors  have  ascertained 
that  fractures  of  the  orbit,  as  frequent  in  1870  as  those 
of  the  cranium,  have  caused,  as  in  previous  wars,  a 
much  lighter  mortality  than  the  latter  (6-9  per  cent, 
instead  of  21-7  per  cent.).  In  the  Crimea,  the  differ- 
ence amongst  our  soldiers  was  less  pronounced  (18*5 
per  cent,  instead  of  28  per  cent.) ;  whilst  during  the 
campaign  of  1866,  the  deaths  following  wounds  of  the 
face  were  five  times  less  numerous  than  the  losses 
from  cranial  lesions  (3'9  instead  of  21*7  per  cent.) ; 
in  Tonquin  the  difference  is  still  more  marked  (4*44 
per  cent,  against  25*28  per  cent.). 

Fractures  of  the  orbit  with  ocular  complications  are 
relatively  frequent,  which  is  doubtless  due  to  the 
slight  resistance  of  the  tissues  of  the  eye,  and  also  to 
its  situation  in  a  bony  cavity,  fractures  of  which  affect 
the  organ  which  it  contains.  The  proportion  of  injuries 
of  the  eye  to  wounds  in  general  is  :  0-5  per  cent. 
(America),  0-81  per  cent  (1870-1871) — a  relation  which 
in  the  Crimea  rose  to  1*75  per  cent.,  and  in  the  Russo- 
Turkish  war  (1877-1878)  to  2-5  or  3  per  cent.  Rela- 
tively to  injuries  to  the  head,  out  of  100  some  5-5  can 
be  reckoned  (America,  War  of  Secession) ;  7*7  (Den- 
mark);  8-5  (1870-1871);  and  in  the  wars  of  the 
Crimea  and  the  Caucasus  the  proportion  was  11-3 
and  18  per  cent.  Finally,  out  of  100  ocular  lesions 
in  the  German  Report  of  1870,  there  are  47*6  of  the 
left  eye,  40*3  of  the  right  eye,  and  9-7  of  both  eyes. 
These  statistics  have  further  established  that,  follow- 
ing injuries  of  the  orbit,  the  eyeball  was  destroyed  in 
only  39-4  per  cent,  of  the  cases,  and  that  small  missiles 
caused  the  loss  of  the  organ  more  often  than  large, 
which  penetrate  less  readily  into  the  orbital  cavity. 
While  on  the  subject  of  these  statistics,  and  to  complete 
them,  we  quote  the  following  details  : — ' 


784  FRACTURES  OF  THE  ORBIT 

(a)  Injuries  of  the  orbit  with  preservation  of  the  eye : — 

1870-1871.  German  Report,  37-6  per  cent. ;  Chenu, 
51*6  per  cent,  of  cases  wounded  by  large  projectiles. 

(b)  Injuries  followed  by  destruction  of  the  eye  : — 

1870-1871.  German  Report,  62-4  per  cent. ;  Chenu, 
73*5  per  cent,  by  small  projectiles. 

1870-1871.  German  Report,  35-9  per  cent. ;  Chenu, 
48-4  per  cent,  by  large  projectiles. 

Otis,  in  the  War  of  Secession,  gives  1190  cases  of 
orbital  gunshot  injuries,  of  which  63  resulted  in  blind- 
ness of  both  eyes,  and  725  in  loss  of  vision  of  one  eye. 

He  adds  51  cases  of  injuries  with  disorder  more  or  less 
marked  of  the  visual  function,  and  256  indeterminate 
cases.  The  mortality  was  considerable  in  the  first 
category,  17  out  of  63;  and  in  the  second  series  57 
out  of  725,  owing  to  cerebral  complications  or  lesions 
of  the  greater  vascular  trunks.  Sympathetic  ophthal- 
mia appeared  very  frequently,  but  Otis  gives  no 
information  on  this  subject. 

Besides  articles  by  Schmidt  (1873),  by  Pan  as 
[Traite  des  Maladies  des  Yeux,  1874),  by  Goldzieher 
{Gunshot  Injuries  of  the  Orbit,  and  sequent  visual  dis- 
orders, 1877),  we  find  a  very  complete  account  by 
Delens  (in  Dwplay  et  Rectus,  Vol.  IV,  p.  508).  Accord- 
ing to  Delens,  who  has  judiciously  weighed  the 
previous  literature  on  the  subject,  when  the  different 
points  of  the  base  of  the  orbit  are  struck  by  a  bullet, 
the  resulting  injuries  are  rarely  limited  to  the  bony 
margin,  and  present  great  variety.  Extension  of  the 
fracture  to  one  of  the  walls  of  the  cavity  is  very 
frequent ;  it  is  especially  so  when  the  superior  wall 
is  involved,  and  in  this  region  assumes  a  peculiar 
gravity,  because  of  the  proximity  of,  and  possible 
damage  to,  the  brain,  which  is  sometimes  laid  bare. 
Fractures  of  the  external  wall  are  the  most  frequent ; 
if  the  projectile  does  not  completely  traverse  the 
orbital  cavity  fracture  uf  the  external  wall  displaces 
the    globe    inwards    and    forwards,    without    directly 


HISTORICAL  785 

injuring  it.  But  most  frequently,  especially  with  the 
penetrating  force  of  modem  projectiles,  the  bullet 
continues  its  path,  fractures  the  internal  wall,  and  if 
its  direction  be  transverse,  breaks  both  walls  of  the 
orbit  on  the  opposite  side,  emerging  through  the 
temporal  fossa.  In  this  course  the  brain  is  often 
injured  at  the  same  time  as  the  visual  apparatus. 
One  has  seen,  rarely  it  is  true,  both  optic  nerves 
simultaneously  divided.  Fractures  of  the  internal 
wall,  by  reason  of  the  proximity  of  the  nasal  fossae 
and  nasal  canal,  give  rise  to  two  almost  constant  signs, 
epis taxis  and  emphysema.  Fractures  of  the  inferior 
wall  are  accompanied  by  injury  to  the  maxillary 
antrum.  Should  the  intra-orbital  nerve  have  been 
injured,  blepharospasm  or  anaesthesia  of  the  cheek 
occur.  Under  other  circumstances,  the  fracture  is 
followed  by  a  falling  in  of  the  eyeball,  which  is  dis- 
placed into  the  antrum  (cases  of  Massot,  Magel,  and 
Langenbeck).  If  the  roof  of  the  orbit  is  involved, 
the  traumatism  is  almost  always  accompanied  by  loss 
of  consciousness,  paralyses,  convulsions  and  coma. 
These  lesions  are  of  peculiar  seriousness,  but  difficult 
at  times  of  diagnosis,  nerve  phenomena  being  the  sole 
symptoms  which  would  cause  their  presence  to  be 
suspected.  The  wound  must  not  be  probed,  and  if 
the  foreign  body  is  still  lodged  in  it  attempts  at 
extraction  are  often  more  dangerous  than  abstention. 

In  the  period  which  extends  from  the  commence- 
ment of  the  twentieth  century  to  the  beginning  of  the 
war  there  is  no  comprehensive  work  dealing  with  the 
subject.  Some  cases  are  recorded,  amongst  which  we 
may  mention  those  of  Coppez  (1899),  fracture  of  the 
orbital  vault  with  contusion  of  the  globe  and  trau- 
matic intra-orbital  adhesion  of  the  levator  palpebrse 
and  superior  rectus ;  of  Laboyenne  and  Moreau 
(1907),  three  cases  of  cranial  fracture  complicated 
with  probable  fracture  of  the  optic  foramen ;  of 
NiEVOLiNA  (1908),  a  case  of  gunshot  wound  of  the 
orbit. 

It  remains  to  point  out  and  recommend  the  two 


786  FRACTURES  OF  THE  ORBIT 

very  complete  articles  by  Rohmer  and  Rollet,  which 
will  be  found  in  extenso  in  the  Encyclopedie  frangaise 
d'Ophtalmologie. 

Rohmer,  after  having  explained  the  mechanism  of 
the  affections  of  the  bony  walls  of  the  orbital  cavity, 
describes  the  various  ocular  complications  which  may 
arise  in  consequence.  He  relates  cases  of  amaurosis 
after  contusion  of  the  orbital  margin — amaurosis 
which  the  ancients  attributed  to  reflex  action,  and 
which  Panas  and  Abadie  set  down  to  effusion  of 
blood  in  the  sheaths.  Delorme,  who  reports  several 
such  cases  from  the  war  of  1870-1871,  has  found 
hypersemia  of  the  optic  disc  and  the  appearance  of 
peri -papillary  pigment  deposits.  This  amaurosis  may 
be  transitory,  or  may  result  in  white  atrophy  of  the 
optic  nerve.  Rohmer  then  enlarges  on  the  intra- 
orbital effusions  of  blood  so  frequently  found ;  upon 
the  cellulitis,  which  is,  on  the  other  hand,  so  rare,  but 
of  grave  import  if  it  accompanies  a  fracture  of  the 
vault ;  upon  acute  oedema  of  the  adipose  tissue 
(Nimier)  ;  upon  injuries  to  the  optic  nerve  (neuritis, 
atrophy,  avulsion,  etc.) ;  and  finally  upon  injuries  to 
the  motor  nerves  and  muscles  of  the  eye  (Wohl, 
Berthold,  Chauvel  and  Nimier's  cases). 

Rollet,  in  the  same  encyclopaedia  (Vol.  VIII,  p.  374), 
studies  in  the  first  chapter  the  indirect  fractures  of 
the  orbit  caused  by  a  fracture,  either  of  the  skull-cap 
or  of  the  base  of  the  skull,  the  mechanism  of  which 
has  been  elucidated  by  the  experiments  of  Aran, 
Felizet,  Braquehaye,  Chipault  and  others,  dealing 
,with  fractures  by  radiation,  contre-coup,  or  smash- 
ing in.  He  next  describes  direct  injuries  and  passes 
in  review  the  different  varieties  of  osseous  lesions 
of  the  walls.  The  copious  list  of  authorities  attached 
to  this  article  has  enabled  the  author  to  set  forth, 
as  well  as  possible  considering  the  few  documents  to 
hand,  the  symptomatology,  prognosis  and  treatment 
of  these  orbital  lesions.  Rollet  has  investigated  all 
the  cases  previously  published  by  clinicians ;  and 
those  interested  in  the  question  will  find  in  this  article 


HISTORICAL  787 

a  complete  bibJiography  which  the  nature  of  our  work 
will  not  permit  us  to  reproduce  here. 

A  recent  thesis,  written  at  our  instigation,  should 
be  noticed.  It  is  by  l^R.  Antonio  de  Menacho,  and 
is  entitled,  "  Heridas  orbito-oculares  en  cirurgia  de 
guerra.''    (Thesis,  Madrid,  1916.) 

The  principal  object  of  this  historical  sketch  is  to 
prepare  the  reader  for  comparing  what  has  been  ob- 
served by  military  surgeons  in  former  wars  with  what 
we  see  in  the  war  to-day. 


CHAPTER  II 

THE   ORBITAL  CAVITY 

Its  Conformation,  its  Protective  R6le,  its 
Resistance  TO  Traumatism,  its  Vulnerability 

The  bones  of  the  face  and  cranium  in  uniting  one 
with  another  form  several  cavities,  the  most  important 
of  which  is  the  orbital  cavity,  destined  to  lodge  the 
eyeball,  the  muscles  which  move  it,  the  vessels  and 
nerves  which  animate  it,  and  the  cellulo -adipose  tissue 
which  surrounds  and  supports  it. 

Conformation 

The  orbital  cavity  has  the  form  of  a  quadrangular 
pyramid,  the  antero -posterior  axis  of  which  is  directed 
obliquely  from  before  backwards  and  from  without 
inwards.  This  comparison  of  the  orbit  with  a  pyramid, 
although  classic,  is  far  from  being  rigorously  correct, 
for  two  reasons.  First,  the  widest  part  does  not 
correspond  to  the  margin  of  the  orbit,  but  is  about  a 
centimetre  behind  (Fig.  1).  Second,  the  edges  of  this 
quadrangular  pyramid  are  so  slightly  marked  that  the 
orbit  really  resembles  a  cone.  The  cast  of  the  orbital 
cavity  shows,  in  fact,  that  its  walls  are  gently  rounded  ; 
indeed,  that  the  comparison  of  the  orbit  with  a  conical 
cavity  is  certainly  the  most  correct  that  can  be  made. 
If,  following  the  classics,  we  still  give  to  it  a  pyramidal 
form,  it  is  because  it  is  more  convenient  for  purposes 
of  description  to  speak  of  a  base,  an  apex,  four  surfaces 
and  four  margins. 

We  shall  adhere  to  this  division,  artificial  though  it 

788 


THE  ORBITAL  CAVITY  789 

may  appear,  and  shall  describe  successively  the  base, 
apex,  the  surfaces  and  the  margins  of  the  orbital 
cavity. 


Fig.  1.  Bones  of  the  Orbit. — 1.  Frontal  bone.  2.  Malar  bone. 
3.  Superior  maxilla.  4.  Superior  portion  of  the  great  wing  of 
the  sphenoid.  5.  Squamous  portion  of  the  temporal  bone.  6.  An- 
terior-inferior angle  of  the  parietal  bone.  7.  Mastoid  process. 
8.  Os  planum  of  ethmoid.  9.  Nasal  bone.  10.  Supra-orbital 
foramen.  11.  Optic  foramen.  12.  Sphenoidal  fissure.  13.  Spheno- 
maxillary fissure.  14.  Infra-orbital  foramen.  15.  Infra-orbital 
groove.  16.  Foramen  for  malar  nerve.  17.  Lacrymal  groove. 
18.  Lesser  wing  of  sphenoid.  19.  Orbital  process  of  palate  bone. 
20.  Lacrymal  bone,  os  unguis. 

Base. — The  base  of  the  orbit,  circumscribed  by  the 
orbital  margin,  has  the  form  of  a  quadrilateral  with 
rounded  angles.     It  is  narrower  than  the  cavit}'  itself, 


790  FRACTURES  OF  THE  ORBIT 

so  much  so  that  a  solidified  cast  of  the  orbit  cannot  be 
withdrawn  intact  without  breaking  the  bones. 

The  circumference  of  the  orbit  is  formed  above  by 
the  supra-orbital  arch  of  the  frontal  bone,  on  each 
side  by  the  angular  processes,  internal  and  external, 
of  the  same  bone ;  internally  and  below,  by  the  nasal 
process  of  the  superior  maxilla  ;  externally  and  above, 
by  the  an tero -posterior  margin  of  the  malar  bone. 

In  passing  the  finger  over  the  orbital  margin  several 
points  are  met  with  which  merit  special  mention. 
Notice  in  the  first  place  the  supra-orbital  notch  or 
foramen  {incisura  supra- orbitalis),  quite  recognisable 
through  the  skin.  This  orifice  is  situated  usually 
twenty-five  millimetres  from  the  median  line.  Very 
often  to  the  inner  side  of  the  supra-orbital  notch  is  to 
be  found  a  small  notch  called  the  incisura  frontalis 
(Merkel).  Outside  this  supra -orbital  notch  one  notes 
that  the  orbital  margin  becomes  particularly  strong, 
prominent  and  resistant. 

Apex. — The  apex  of  the  orbit  corresponds  to  the 
most  internal  and  widest  portion  of  the  sphenoidal 
fissure.  This  fissure  is  situated  along  the  internal 
border  of  the  great  wings,  and  is  the  space  between 
this  border  and  the  inferior  surface  of  the  lesser  wings. 
The  fissure,  whose  outline  somewhat  resembles  that 
of  a  club,  is  wide  internally  and  narrow  externally, 
where  it  tapers  off  and  is  lost  under  the  processes  of 
Ingrassias  (the  lesser  wings).  The  sphenoidal  fissure 
transmits 'the  third  and  fourth  nerves,  the  ophthalmic 
branch  of  the  trigeminal,  the  sixth  nerve,  the  ophthal- 
mic vein,  a  prolongation  of  the  dura  mater,  and  an 
arteriole,  a  branch  of  the  middle  meningeal.  To  the 
internal  margin  of  the  fissure  is  attached  the  ring  of 
Zinn,  inserted  into  a  small  bony  tubercle,  more  or  less 
developed  according  to  the  subject. 

Walls  and  Surface. — The  walls  of  the  orbit  are  four 
in  number  :  superior,  inferior,  external,  internal. 

The  superior  wall  or  roof  is  formed  by  two  bones ; 
the  orbital  plate  of  the  frontal  and  the  inferior  surface 
of  the  lesser  wing  of  the  sphenoid.     It  takes  the  form 


THE  ORBITAL  CAVITY  791 

of  a  cupola,  especially  in  its  anterior  part,  by  reason  of 
the  orbital  margin  which  overhangs  and  tends  to  make 
the  bend  of  the  arch  seem  deeper. 

In  examining  this  superior  wall  of  the  orbit,  there 
are  to  be  seen  :  in  front  and  externally,  the  lacrymal 
fossa  in  which  is  lodged  the  gland  of  the  same  name, 
behind  this  the  suture  of  the  frontal  with  the  lesser 
wing  of  the  sphenoid,  externally  that  which  unites  the 
frontal  with  the  great  wing  of  the  sphenoid  ;  internally, 
that  which  joins  the  same  bone  with  the  paper-like 
OS  planum  of  the  ethmoid.  These  sutures  are  quite 
invisible  in  the  orbit  when  covered  with  periosteum. 

The  superior  wall  of  the  orbit  is  remarkable  for  its 
thinness ;  upon  the  dry  bone,  when  the  light  passes 
through  from  above,  the  digital  impressions  of  the 
anterior  cerebral  cavity  can  be  readily  seen.  It 
should  be  noticed,  however,  that  in  the  internal 
portion,  in  the  adult,  and  still  more  in  the  aged,  this 
surface  is  covered  to  a  greater  or  less  extent,  by  the 
frontal  sinus,  which  is  sometimes  very  large. 

The  inferior  wall  or  floor  is  formed  by  the  superior 
surface  of  the  pyramid  of  the  superior  maxillary  bone 
(the  orbital  process)  and  by  the  superior  surface  of 
the  orbital  process  of  the  malar  bone ;  posteriorly  is 
to  be  seen  the  little  orbital  facet  of  the  palate  bone. 
This  wall  is  smooth  and  regular,  its  highest  portion  is 
towards  the  inner  side ;  thence  the  surface  inclines 
forwards  and  laterally ;  it  is  slightly  concave  on  the 
whole,  but  this  concavity  is  not  well  marked ;  it  may 
even  give  place  to  a  certain  amount  of  convexity,  due 
to  the  maxillary  antrum,  which,  like  the  frontal  sinus, 
may  attain  excessive  dimensions  and  become  dis- 
tended, and  so  in  a  manner  raise  the  wall  which 
separates  it  from  the  orbit. 

Besides  the  sutures  which  unite  the  superior  maxilla, 
the  malar,  and  the  palate  bone,  on  the  floor  of  the 
orbit  is  seen  the  intra-orbital  groove,  which,  after  a 
course  averaging  two  centimetres,  becomes  a  complete 
canal,  the  intra-orbital  canal.  The  length  of  the 
groove  in  proportion  to  that  of  the  canal   varies  in 


792  FRACTURES  OF  THE  ORBIT 

different  subjects ;  before  it  is  roofed  in  by  a  plate 
of  bone,  the  groove  is  changed  into  a  canal  by  a 
fibrous  membrane  which  is  continuous  with  the 
periosteum  of  the  orbit. 

When  the  inferior  wall  of  the  orbit  is  examined  on 
the  living  or  dead  subject  the  nerve  is  visible  as  a 
whitish  cord,  owing  to  the  transparency  of  the 
periosteum. 

The  external  wall  is  formed  by  three  bones  :  the 
great  wing  of  the  sphenoid,  the  orbital  process  of  the 
malar  bone,  and  the  most  external  portion  of  the  orbital 
plate  of  the  frontal  bone. 

The  portion  of  this  surface  which  belongs  to  the 
sphenoid  is  limited  by  the  sphenoidal  and  the  spheno- 
maxillary fissures ;  at  this  level  the  wall  is  fiat ;  in 
front  it  is  a  little  rounded ;  everywhere  it  is  smooth, 
except  in  the  vicinity  of  the  sphenoidal  fissure ;  quite 
at  the  posterior  part  there  is  a  bony  projection  in  the 
form  of  a  spine,  which  serves  for  insertion  of  a  portion 
of  the  external  rectus  (the  lower  head). 

The  sutures  on  this  surface  which  unite  the  three 
bones,  the  malar,  frontal,  and  sphenoid,  have  the  form 
of  a  T,  the  horizontal  branch  of  which  extends  from 
the  outer  extremity  of  the  sphenoidal  fissure  to  the 
external  and  superior  angle  of  the  base  of  the  orbit, 
while  the  vertical  branch,  separating  the  malar  bone 
from  the  great  wing  of  the  sphenoid,  reaches  the 
anterior  extremity  of  the  spheno -maxillary  fissure. 
Further,  on  this  surface  must  be  noted  the  malar 
canal,  which,  commencing  on  the  superior  surface  of 
the  orbital  process  of  the  malar  bone,  bifurcates  in 
the  interior  of  the  bone  to  open  both  on  the  internal 
and  external  surfaces  ;  these  two  canals  give  passage 
to  nerve  filaments  of  the  orbital  branch  of  the  superior 
maxillary  nerve. 

We  will  cut  short  this  description,  which  must  of 
necessity  be  brief ;  it  will  suffice  if  the  reader,  to  grasp 
what  follows,  will  carefully  examine  Fig.  1. 


THE  ORBITAL  CAVITY  793 

The  Protectr^e  ROle  of  the  Orbit 

Just  as  the  cervical  and  dorsal  vertebrae  protect  the 
spinal  cord  and  the  lumbar  vertebrse  the  cauda  equina, 
in  the  same  manner  the  cranial  vertebrae  protect  the 
encephalon  and  those  advanced  portions  of  the  nervous 
system  which  are  the  sensory  nerves,  notably  the  optic 
nerve  and  the  retina. 

We  are  not  concerned  with  taking  sides  for  or 
against  the  vertebral  theory  of  the  cranium ,  we  are 
quite  aware  that  it  is  a  much-discussed  question,  but 
we  cannot  forget  that  certain  anatomist  philosophers 
(Goethe,  Oken)  have  not  hesitated  to  describe  four 
cranial  vertebrae,  and  to  find  in  each  of  them  the 
constituent  portions  of  a  typical  vertebra — a  vertebral 
bod}^  two  vertebral  arches  and  a  spinous  process. 
Those  who  accept  these  vertebrae  classify  them  thus  : 
Occipital,  spheno -parietal,  frontal  and  nasal ;  it  is  the 
third,  the  spheno -frontal  vertebra,  wliich  interests  us ; 
its  body  is  represented  by  the  body  of  the  anterior 
sphenoid,  its  foramen  by  the  ethmoid  notch,  its 
laminae  by  the  lesser  wings  of  the  sphenoid  and  the 
frontal  bone  :  it  is  this  which  forms  the  orbital 
chamber  for  the  protection  of  the  retina. 

Grave  objections  have  been  brought  against  this 
theory.  It  is  certain  that  the  cranial  bones  have  a 
special  evolution;  the  base  of  the  cranium  comes 
from  the  endoskeleton,  the  cartilaginous  skeleton, 
while  the  vault  comes  from  the  exoskeleton,  the 
dermic  skeleton ;  besides,  above  the  basilar  process, 
the  notochord  is  no  longer  present,  and  no  notochord, 
no  vertebrce.  Finally,  in  the  cranium  a  phenomenon 
constant  in  the  vertebral  column  is  absent,  viz.  the 
appearance  of  small  cubical  masses  separated  by 
transverse  lines,  called  proto vertebrae.  The  cranium 
has  no  protovertebrae.  However,  these  objections  have 
not  prevented  Kolliker  from  accepting  the  verte- 
bral theory  of  the  cranium,  relying  upon  the  presence 
of  certain  swellings  in  the  cephalic  portion  of  the 
notochord,  and  upon  the  presence  during  foetal  life 


794  FRACTURES  OF  THE  ORBIT 

of  intervertebral  discs ;  one  of  the  most  anterior  of 
these  discs,  the  third,  is  between  the  body  of  the 
anterior  sphenoid  and  the  posterior  sphenoid.  It 
belongs  to  the  vertebra  which  surrounds  and  protects 
the  eye. 

Admitting  that  the  vertebral  tlieory  of  the  cranium, 
properly  so  called,  is  no  longer  acceptable,  there 
remains  what  is  termed  the  segmental  theory  of  the 
cranium  (Hertwig),_  which  consists  in  supposing  that 
the  head  of  the  vertebrae  is  the  anterior  prolongation 
of  the  trunk,  and  that,  like  the  latter,  it  is  composed 
of  metameres  {Cephalic  metamery),  in  each  of  which 
three  elements  should  be  found — a  mesodermic  seg- 
ment, a  skeletal  segment,  and  a  nervous  segment. 
It  is  evident  that  the  cephalic  metamery  is  much  more 
complicated  than  that  of  the  trunk,  because  the  meta- 
meres of  the  head  are  sometimes  divided  into  two, 
sometimes  blended,  and  the  different  segments,  meso- 
dermic, skeletal  and  nervous,  atrophy  or  develop 
according  to  the  necessary  adaptations  of  the  organism. 

Whatever  share  of  scientific  truth  may  be  comprised 
in  these  different  theories,  it  is  none  the  less  true  that 
the  fragment  of  brain  which  we  term  the  optic  nerve 
(commissural  nerve),  and  the  retina  (cortical  sub- 
stance) find,  in  what  the  partisans  of  the  vertebral 
theory  of  the  cranium  call  the  third  vertebra,  an 
efficient  protection  against  traumatism.  The  box  of 
bone  which,  like  a  substantial  coffer  containing  a 
precious  treasure,  guards  the  cerebro -spinal  axi^  is 
widely  open  at  the  level  of  the  eye,  because  it  is 
necessary  that  the  eye  should  search  the  space  in  front 
of  it ;  but  behind  and  on  every  side,  this  box  is  solid 
and  efficacious  as  a  protective  mechanism.  Let  us 
see  by  what  fortunate  arrangements  it  is  enabled  to 
resist  injury. 


Resistance  to  Injury 

It  will  be  convenient  to  consider  successively  the 
base  of  the  cavity  and  its  four  walla. 


THE  ORBITAL  CAVITY  795 

Resistance  of  the  Base. — The  base  of  the  orbital  cavity 
IS  built  up,  as  we  have  seen,  by  the  frontal,  malar,  and 
superior  maxillary  bones.  These  are  three  bones  of  great 
resisting  power ;  a  violent  blow  will  be  needed  to  fracture 
them,  and  in  the  mechanism  by  which  they  are  locked 
together  we  again  find  conditions  which  add  to  the 
solidity  they  already  possess  from  their  thickness  and 
the  compactness  of  their  substance. 

In  fact,  it  is  evident  that  a  traumatism,  affecting 
the  upper  portion  of  the  orbit  at  the  level  of  the 
orbital  arch,  will  be  immediately  communicated  to 
the  two  pillars  represented  by  the  internal  orbital  and 
the  external  orbital  processes  of  the  frontal  bone ;  the 
malar  bone,  so  firmly  locked  into  the  facial  founda- 
tion, and  the  superior  maxilla,  by  means  of  its  highly 
resistant  upper  portion,  receive  the  shock.  The 
vibrations  produced  by  the  blow  of  a  blunt  instrument 
will  be  spread  over  the  bones  of  the  face.  In  the 
same  manner,  the  shock  of  the  stroke  of  a  hammer, 
handled  by  a  giant,  falling  on  the  dome  of  a  cathedral 
would  be  lost  in  the  ground.  If  it  is  suggested  further 
that  the  vault  of  the  orbital  arch  is  a  vault  like  a 
basket-handle  of  the  Roman  type  it  will  be  seen  how 
difficult  it  is  to  break  it. 

Should  the  blow  strike  the  inferior  orbital  arch,  the 
same  conditions  of  resistance  will  be  found.  There 
again  it  is  a  question  of  an  arch  and  a  vault,  and  the 
blow,  falling  on  the  superior  border  of  the  maxilla  or 
the  horizontal  ramus  of  the  malar  bone,  will  be  pro- 
pagated in  the  inverse  direction  to  that  of  the  shock 
to  the  superior  arch,  but  under  the  same  general 
conditions.  The  two  orbital  processes  of  the  frontal 
bone  in  this  case  form  the  pillars ;  and  the  Roman 
vault,  here  as  in  the  superior  arch  of  the  orbit,  efficiently 
resists  violent  blows.  When  the  injury  affects  the 
superior  part  of  the  orbit,  its  power  will  be  dispersed 
in  the  facial  mass  ;  when  it  concerns  the  inferior  part, 
the  vibrations  it  sets  up  in  the  bones  are  lost  in  the 
cranial  mass. 

Finally,    when    a    blow   from    a    blunt   instrument 


796  FRACTURES  OF  THE  ORBIT 

strikes  directly  the  external  wall  of  the  orbit,  the  malar 
bone. itself,  it  meets  a  particularly  efficacious  resist- 
ance ;  for  outside  the  pillars  which  receive  the  shock, 
and  which  are  in  this  case  the  superior  maxillary  and 
the  external  process  of  the  frontal,  we  find  the  zygo- 
matic arch,  which  is  quite  comparable  with  the  flying 
arches  by  means  of  which  architects  strengthen  Gothic 
cathedrals.  The  crushing  in  of  such  a  vault  is  par- 
ticularly difficult ;  if  a  blow  were  struck  on  the  dome 
of  Notre  Dame,  the  shock  would  be  lost  in  the  ground 
and  would  be  transmitted  there  by  the  retaining  walls 
or  by  the  pillars,  and  by  the  flying  buttresses.  If  a 
blow  were  struck  on  the  malar  bone,  the  two  pro- 
cesses, frontal  and  maxillary,  of  that  bone  would 
transmit  the  vibrations  through  the  superior  maxillary 
and  the  frontal,  whilst  the  zygomatic  arch,  a  veritable 
cathedral  flying  buttress,  would  transmit  them  to  the 
temporal.  The  base  of  the  orbit  resists  the  shock  both 
like  a  Roman  church  and  like  a  Gothic  cathedral. 

Resistance  of  the  Walls. — The  wall  of  the  orbital 
cavity  is  extremely  resistant  from  without ;  it  is  still 
solid  below,  but  is  thinner  above,  and  paper-like  within. 
Besides  the  thickness  of  its  skeletal  structures,  the  wall 
possesses  in  the  mass  of  muscle  covering  the  temple  a 
most  valuable  defence,  and  on  this  side,  which  is  really 
the  only  one  exposed  to  traumatism,  the  eye  is  well 
protected.  Moreover,  when  a  blow  reaches  the  external 
wall  with  sufficient  force  to  cause  fracture  the  track 
of  the  fracture  cannot  go  very  far;  it  is  immediately 
checked  above  and  below  by  the  horse-shoe,  concavity 
outwards,  formed  by  the  united  sphenoidal  and  spheno- 
maxillary fissures. 

The  inferior  wall  is  protected  by  the  entire  bulk  of 
the  face ;  to  reach  it,  a  projectile  or  a  line  of  fracture 
must  have  in  the  first  place  involved  the  inferior 
maxUla  and  have  crossed  the  antrum ,  besides,  the 
wall  is  relatively  thick,  since  it  contains  in  its  structure 
protection  for  an  important  nerve  trunk,  the  intra- 
orbital. 

The  internal  wall  is  slight,  like  the  os  planum  of  the 


THE  ORBITAL  CAVITY  797 

ethmoid  which  forms  the  greater  part  of  it,  but  it  is 
protected  by  all  the  ethmoidal  cells,  and  is  only 
reached  when  the  traumatism  has  already  produced 
great  destruction  in  the  surface  of  the  opposite  side. 
In  this  situation  Nature  has  no  need  to  oppose  a  strong 
barrier,  the  eye  being  protected  by  the  actual  thick- 
ness of  the  tissues  and  organs  which  separate  it  from 
the  opposite  side ;  the  delicacy  of  the  wall  is  not  a 
disadvantage,  so  far  as  injury  is  concerned.  But 
it  is  emphatically  so  from  the  point  of  view  of  the 
facility  with  which  neoplasms,  arising  in  the  nasal 
cavities,  affect  the  orbit,  deflecting  at  first,  and  later 
perforating,  the  slight  partition  which  separates  them 
from  the  orbital  cavity. 

The  superior  wall  of  the  orbit  is  equally  thin,  and 
more  than  this,  it  is  at  the  same  time  orbital  wall 
and  cranial  wall.  It  is  this  latter  detail  which  ex- 
plains why  it  is  often  injured.  Of  all  the  orbital  walls 
it  is  perhaps  that  most  often  wounded,  and  this  occurs 
because  it  can  share  in  the  cranial  fractures  (whose 
role  will  be  studied  later),  and  also  because  direct 
shocks  on  the  superior  orbital  arch  are  easily  conducted 
to  it. 

Application  of  the  Laws  of  Dynamics  to  the  Orbit. — 
In  making  use  of  the  classic  data  put  to  profit  by 
engineers  and  architects  we  can  ascertain  precisely 
and  scientifically  the  manner  in  which  the  bones  of 
the  orbit  offer  resistance. 

In  the  first  place  we  may  consider  the  structure  of 
the  bones  which  constitute  the  cavity;  in  the  second 
place  the  specialised  architecture  of  the  orbital 
vaults. 

(1)  The  bones  of  the  orbit,  like  those  of  the  cranium, 
are  composed  of  two  laminae  separated  by  spaces 
filled  with  bone-marrow ;  this  separation  is  very  favour- 
able to  resistance. 

Thus,  when  a  steel  bullet  is  fired  at  a  plate  seven 
millimetres  thick,  it  will  pierce  the  plate  of  metal. 
Let  this  plate  be  split  in  two,  and  in  the  interval 
between  the  two  plates,   place  sawdust,   compressed 


798  FRACTURES  OF   THE  ORBIT  ' 

paper,  or  cork-powder  \  the  buQet  will  not  penetrate 
the  two  half -plates  and  their  intermediate  packing. 

The  projectile  loses  force  in  passing  successively 
through  media  of  varying  density. 

The  frontal  bone  at  its  upper  part,  the  malar  bone, 
and  the  outer  and  inferior  walls  of  the  orbit  may  be 
compared  to  a  metallic  plate  in  two  layers  separated 
by  a  less  dense  substance,  which  is  bone-marrow. 

(2)  Fig.  2  will  demonstrate,  without  further  words 
(save  the  accompanying  explanation),  how  forces  which 
attack  the  eye  on  the  superior  orbital  region,  on  the 
malar  bone,  or  on  the  inferior  orbital  region,  act  and 
are  resolved. 

Vulnerability  of  the  Orbit 

The  cavity  of  the  orbit  in  general  is  well  protected 
where  it  is  closed,  but  Nature  has  decreed  that  it 
should  be  vulnerable  by  reason  of  its  numerous  and 
wide  apertures. 

We  will  not  discuss  the  principal  opening.  The  eye 
is  very  fortunate  in  avoiding  injury  attacking  it  from 
the  front,  although  nothing  protects  it  beyond  the 
membranous  shield  of  the  eyelids.  Yet  this  shield 
fails  when  the  nature  or  the  speed  of  the  projectile 
render  it  invisible. 

But  it  is  not  alone  by  tlje  base  of  the  orbit  that 
the  cavity  is  vulnerable.  The  cavity  communicates 
by  important  orifices  :  (1)  with  the  cranium  by  the 
optic  foramen  and  the  sphenoidal  fissure ;  (2)  with 
the  soft  tissue  of  the  facial  mass  and  the  pterygo 
maxillary  fossa. 

The  optic  foramen,  and  especially  the  sphenoidal 
fissure,  readily  allow  sanguinary  effusions  to  pass  from 
the  base  of  the  cranium.  Orbital  hsematomata  and 
exophthalmias  occur,  which  are  due  solely  to  this 
cause,  but  it  is  especially  the  fissure  and  the  pterygo - 
maxillary  fossa  which  so  well  explain  how  injuries 
to  this  region  may  involve  the  eyeball.  There  is  by 
this  relatively  large  opening  a  ready  communication 
between  the  orbital  tissues  and  the  soft  parts,  retro- 


Fig.  2. — Application'  of  dynamic  laws  to  the  study  of  injuries  to 
the  orbit. 

A  and  A'.  Blow  delivered  on  the  superior  part  of  the  orbital  arch. 
This  force  divides  into  two  components,  thus  :  P  —  OP'  +  OP". 
The  total  resultant  of  the  forces  due  to  propulsive  force  and  weight 

must  pass   between  0  and  C  so  that  MC  =     a    ;    to  obtain  this 

result,  it  is  necessary  to  enlarge  the  surface  of  the  base  of  the  courses 
(foundation) :   hence  the  presence  of  the  malar  bone. 

The  resultants  R'  and  R"  which  converge  towards  the  nose, 
being  equal  and  opposite,  neutralise  each  other  (principle  of  bridge 
piers). 

B.  Blow  delivered  on  the  malar  bone. — The  force  in  this  case  is 
resolved  into  three  other  forces  whose  resultants  are  lost  in  the 
process  of  the  frontal  bone  =  zygomatic  arch  (flying  buttress  of 
Gothic  cathedral)  and  maxilla. 

C.  Blow  on  the  maxilla. — The  shock  is  resolved  into  two  forces. 
The  resultant  of  one  is  lost  in  the  malar  bone  and  the  second  in 
the  upper  portion  of  the  superior  maxillary  bone. 

799 


800 


FRACTURED  OF  THE  ORBIT 


maxillary  and  jugular  (Fig.  3).  Let  a  bullet  or  a  piece 
of  shrapnel  penetrate  sharply,  either  into  the  facial 
bony  mass,  or  the  soft  parts,  or  more  frequently  into 
both,  then  by  virtue  of  Pascal's  hydrostatic  law  the 
rapid  vibrations  wliich  result  are  transmitted  to  the 
orbit  by  the  ptery go -maxillary  fissure ;  the  eye  is 
struck  after  the  manner  of  a  rock  submerged  in  the 


rroutal. 


Nasal. 


Lacrymal. 


Palate. 


Anterior  nascl 
spine. 


Fig.  3. — Ptery  go -maxillary   fossa   (anterior  wall   and   posterior 
opening). 

sea  and  shaken  by  a  deep  wave.  The  first  result  of 
such  a  commotion  in  the  orbit  is  the  pushing  forward 
of  the  eye  as  though  to  make  it  come  forth  from  its 
normal  situation,  in  spite  of  the  optic  nerve  which 
resists  and  pulls  it  back,  with  more  or  less  force, 
sometimes  leading  to  rupture  of  the  posterior  part  of 
the  globe. 

If  we  take  into  consideration  the  speed  and  the 
force  of  modern  projectiles  we  shall  understand  that 


THE  ORBITAL  CAVITY  801 

the  contents  of  the  eye  and  its  deep  membranes 
cannot  readily  support  such  indirect  and  mediate 
traumatism,  and  that  from  it  will  result  lesions,  the 
descriptions  of  which  will  constitute  one  of  the  original 
features  of  the  essay  we  have  undertaken. 


CHAPTER  III 

GENERAL  CONSIDERATIONS  UPON  THE 
iETIOLOGY   OF  FRACTURES   OF  THE   ORBIT 

Their  Frequency,  Varieties  and  Pathogenesis 

Fractures  of  the  orbit  by  projectiles  of  war  hold 
an  important  position  in  actual  warfare,  and  they  are 
important  especially  from  the  effect  they  have  upon  the 
visual  apparatus  and  upon  the  organs  which  occupy 
the  vicinity  of  the  orbital  cavity. 

The  following  is  a  synoptical  table  which  will  show 
to  the  reader  both  a  general  survey  of  the  Service 
d'Ophtalmologie  de  la  18'  Region  and  the  importance 
of  the  subject  we  are  engaged  in  studying. 


Fractures  of  the  Orbit 

609  cases  out  of  2554  wounds  inflicted  in  war. 

Per  cent. 

(1)  With  preservation  of  the  eyeball        .    397  say  65-5 

(2)  With  destruction  of  the  eyeball  .   212    „    34-5 

{a)  With  preservation  of  the  eye, 

without  ocular  lesion  of  anv 

kind '^     105    „    17-2 

(6)  With  ocular  lesions    .        .        .    ^92    „    47-9 

These  lesions  are  : — 

(1)  Detachment  of  the  retina  .        .      40    ,,      6-5 

(2)  Choroido -retinitis,      atrophic      and 

pigmented,  macular  and  equatorial  94    ,,    15*5 

(3)  Choroido -retinitis  proliferans     .        .      45    ,,      7*3 

(4)  Atrophy  of  optic  nerve  .        .      29    ,,      4-7 

802 


GENERAL  CONSIDERATIONS 


HOI] 


Per  cent. 

(5)  Laceration  of  optic  nerve           .        .  4  say  0-65 

(6)  Section  of  optic  nerve         .                .  12    .,      1-96 

(7)  Optic  neuritis,  or  retrobulbar  neuritis  22    ,,      3-6 

(8)  Haemorrhage  into  the  vitreous          .  31    ...      5 

(9)  Total  cataract      .....  7    .,      1*15 

(10)  Subluxation  of  the  lens      .        .        .  2    „      0-32 

(11)  Corneal  lesions  alone          ...  6    ,,     0*98 


Furthermore, 
observed  : — 


amongst    these    fractures    we    have 


(1)  Complications  in  adjoining  cavities—  Percent. 

ci-         I  frontal       ....  31  sav    5 

OmUS  i                .,,  1  ir.              1  o  n 

( maxilhiry                  .        .  110    ,,    18-2 

Brain       .        .     \        .        .        .  13    ,,      2-1 

(2)  Complications  of  sensory  nerves        .  43    ,,     7 

(3)  Complications  of  muscles — 

Extrinsic         .        .        .        .        .  23    „      3-77 

Intrinsic          .        .        .        .        .  4    ,,      0-65 

(4)  Blepharospasm   from   lesion  of   the 

infra-orbital  nerve         .        .        .  2    ,,      0*32 

(5)  Cellulitis  of  the  orbit           ...  2    '„     0-32 

(6)  Complications  of  the  lacrymal  pas- 

sages          25    ,,      4-1 

The  muscular  lesions  are  divided  thus 
(1)  Paralysis  of  the  levator  palpebrse 


(2) 
(3) 
(4) 
(5) 
(6) 
(7) 
(8) 

(9) 


,,   superior  rectus 

,,   inferior  rectus 

,,   internal  rectus 

,,   external  rectus 

.,   superior  oblique 

,,  inferior  oblique 
several  nerves  simultaneously 
intrinsic  muscles  alone 


The  fractures  which  bring  about  these  affections 
may  be  divided  into  direct  and  indirect  fractures ; 
but  they  occupy  in  this  respect  positions  singularly 
unequal ;   for    while    direct    fractures    are    extremely 


804  FRACTURED  OF   THE  ORBIT 

common  in  our  service,  it  is  impossible  to  quote 
more  than  two  clear  cases  of  indirect  fracture.  We 
must  emphasise  this  clinical  datum,  which  merits 
consideration. 

Indirect  fractures  are  sometimes  fractures  radiated 
from  the  superior  portion  or  the  base  of  the  cranium 
to  the  orbital  vault,  or  sometimes  fractures  by  contre- 
coup  ("independent,"  Trelat),  which  continue  the 
general  directions  of  a  line  of  cranial  fracture.  To 
judge  from  the  classic  authorities,  and  from  the  best 
of  them,  this  type  of  orbital  traumatism  should  form  a 
prominent  feature  in  the  practice  of  ocular  surgery, 
and  cranial  fractures — of  wliich  we  do  not  need  here 
to  recall  the  numerous  theories — should  frequently 
implicate  the  sphenoid  and  the  frontal  in  their  orbital 
portion.  Such  is,  however,  not  the  case,  for  these 
lesions  are  extremely  rare. 

Doubtless  the  objection  might  be  raised  that  such 
injuries  have  not  come  under  our  notice,  because  the 
cases  have  not  had  time  to  arrive  at  the  base,  where  we 
have  been  engaged  in  the  study  of  military  ophthal- 
mology, or  perhaps  still  more  that,  amongst  the  im- 
portant accidents  experienced  by  the  wounded,  orbital 
injuries  have  passed  unnoticed,  and  that  general 
surgeons  alone  have  been  able  to  observe  the  variations 
in  fractures  of  the  vault  of  the  orbit. 

This  latter  objection  loses  all  its  force  precisely 
because,  in  the  Service  Central  de  la  18^  Region,  we 
met  mth  a  large  number  of  very  important  cranial 
injuries  which  we  observed  with  particular  care. 
These  were  cases  of  fractures  of  the  skull  in  the 
parietal  and  occipital  regions  which  presented  visual 
trouble,  and  in  particular,  hemianopia.  Our  pupil, 
Dr.  Beauvieux,  has  written  an  elaborate  memoir  on 
this  subject,  not  yet  published,  dealing  -with  cases  in 
which  cranial  traumatism,  always  very  important,  was 
sometimes  pre-eminent.  It  treats  of  fractures  by  bullet 
or  by  shell  which  have  made  great  breaches  in  the 
cranial  walls  and  often  caused  fractures  to  radiate  to 
great  distances. 


GENERAL  CONSIDERATIONS  805 

In  none  of  these  cases  has  the  optic  nerve  been 
implicated ;  in  none  of  them  have  the  structures 
passing  through  the  sphenoidal  fissure  been  damaged. 
We  must  conclude  that  there  have  not  been  fracture - 
radiations  over  the  vault  of  the  orbit ;  and  if,  indeed, 
such  traumatisms  have  neither  produced  fracture  by 
radiation  nor  independent  fracture  by  contre-coup 
we  must  deduce  that,  in  sound  military  ophthalmology, 
there  is  no  need  to  attach  importance  to  a  lesion 
whose  frequency  has  been  singularly  exaggerated  in 
previous  literature 

Furthermore,  we  are  not  the  only  authors  who  have 
studied  visual  disturbances  consequent  on  traumatism 
of  the  cranial  regions  which  cover  the  visual  psychic 
lobes ;  Pierre  Marie  and  Chatelin  have  published  a 
very  important  essay  on  this  subject  in  the  Revue  de 
Neurologie  (December,  1915,  Nos.  23  and  24).  In  this 
they  report  thirty-six  observations  of  cranial  fracture, 
of  which  thirty-one  were  complicated  by  hemianopic 
modifications  of  the  fields  of  vision.  In  all  these  cases, 
save  one,  the  authors  have  noted  no  damage  to  the 
transparent  media  nor  to  the  deep  ocular  membranes, 
nor  to  the  intrinsic  or  extrinsic  muscles  which  might 
suggest  a  fissure  radiating  into  the  orbit.  The  diplopia 
mentioned  in  two  or  three  of  the  cases  has  rapidly 
disappeared,  and  did  not  seem  to  be  the  consequence 
of  attrition  of  nerve  filaments  at  the  site  of  the 
sphenoidal  fissure. 

In  Case  XXXI,  however,  Marie  and  Chatelin 
found  A  double  optic  atrophy,  but  they  attribute  it 
to  a  diffuse  lesion  of  the  chiasma,  the  patient  having 
had  a  cerebral  abscess  with  meningeal  trouble. 

We  have  had  another  proof  of  the  extreme  rarity 
of  radiating  fractures  and  fractures  by  contre-coup  of 
the  orbital  vault ;  it  is  that  we  have  never  been  able, 
in  the  numerous  radiograms  which  we  have  had  placed 
at  our  disposal,  to  see  a  fissure  track  indicating  a 
solution  of  continuity  of  the  vault  extend  as  far  as 
the  sphenoidal  fissure.  We  are  quite  aware  that  it  is 
a  difficult  region  to  radiograph,  and  that  this  may  be 


80G  FRACTURES  OF  THE  ORBIT 

the  explanation  of  the  absence  of  any  trace  of  frac- 
ture upon  our  negatives ;  but  as,  on  the  other  hand, 
there  is  no  symptom  indicating  that  the  motor  or 
sensory  nerves  of  the  eye  have  been  damaged  in  the 
optic  foramen  or  the  sphenoidal  fissure,  it  must  be 
concluded  that  the  orbital  cavity  in  general  does  not 
suffer  by  radiation  or  contre-coup  in  the  gravest 
gunshot  fractures  of  the  cranial  vault. 

Twice  only  have  we  found  this  condition ;  in  one 
case  the  fracture  was  by  radiation;  in  the  other,  by 
contre-coup.  What  are  2  out  of  609  cases  of  fracture 
of  the  orbit  ? 

The  607  other  cases  which  have  been  examined  by 
us  have  been  direct  fractures. 

These  direct  fractures  have  been  produced  by  bullets 
(150  times),  by  shrapnel  (14  times)  and  by  shell 
fragments  (440  times).  Menacho  has  noted  that  more 
than  half  the  orbito-ocular  injuries  were  produced  by 
bullets,  because  he  studied  the  injuries  at  the  outset 
of  the  campaign ;  later  on,  during  the  trench  warfare, 
shells  have  played  a  much  greater  part.  These  injuries 
sometimes  affected  the  wall  of  the  orbit,  sometimes  the 
margins ;  it  was  the  bullets  especially  that  injured 
the  walls,  and  they  often  perforated  and  traversed 
both  orbits.  All  ophthalmologists  have  seen  soldiers, 
both  of  whose  optic  nerves  have  been  injured,  some- 
times divided  by  the  same  projectile.  The  pointed 
bullet,  conical  and  endowed  with  great  velocity,  after 
having  traversed  the  bony  walls,  readily  passes  into 
the  neighbouring  cavities.  Shrapnel  balls,  on  the 
contrary,  having  less  velocity,  very  often  remain 
in  the  orbit.  We  have  removed  a  number  of  them 
with  or  without  preservation  of  the  eye ;  the  same 
applies  to  shell  fragments.  Very  rarely  do  they  pass 
beyond  the  orbital  cavity  to  lodge  in  the  nose,  the 
antrum,  or  the  cranium ;  often,  indeed,  they  are 
checked  by  the  orbital  wall,  driving  it  in  witho\it 
passing  through  it,  but  they  produce  grave  commo- 
tion in  the  contents  of  the  cavity  before  coming  to 
rest  against  one  of  the  walls. 


GENERAL  CONSIDERATIONS  807 

Pathogenesis 

Three  theories  have  been  advanced  to  explain  the 
mechanism  of  indirect  fractures  of  the  orbit  by  gun- 
shot wounds — 

(1)  The  scattering  of  the  projectile,  fragments  of 
which  strike  the  internal  wall  of  the  cranium. 

(2)  The  cone  of  air  produced  by  the  flight  of  the 
bullet  is  the  true  projectile  capable  of  smashing  the 
wall  of  the  cranium. 

(3)  The  hydrostatic  pressure,  based  upon  Pascal's 
law.  The  projectile  when  entering  the  cranial  cavity 
produces  a  sudden  increase  of  pressure  which  is  trans- 
mitted with  equal  force  over  the  whole  internal  surface 
of  the  cranium.  The  orbital  vault  being  the  thinnest 
portion  of  the  cranial  wall  should  therefore  be  frequently 
fractured. 

The  last  theory  would  appear,  a  priori,  to-  appeal 
to  the  judgment,  and  with  Braquehaye  and  Chtpault 
we  were  quite  disposed  to  accept  it,  if  clinical  expe- 
rience had  demonstrated  to  us  the  existence  of  such 
fractures;  but  since,  as  we  have  said  above,  we  have 
studied  minutely  all  the  visual  signs  of  the  very  large 
number  of  cases  which  have  suffered  from  the  entry 
of  projectiles  into  the  cranium  without  meeting  with 
a  single  instance  in  which  the  orbital  roof  was  fissured, 
we  cannot  attach  great  importance  to  a  theory  which 
is  not  upheld  by  the  facts.  We  do  not  further  labour 
the  point,  but  we  wish  to  make  use  of  the  wealth  of 
material  at  our  disposal  to  point  out  that,  in  gun- 
shot wounds  of  the  cranium,  fractures  of  the  orbital 
roof  are  produced  neither  by  radiation  nor  by  contre- 
coup. 

With  the  help  of  Dr.  Beauvieux,  who,  moreover, 
has  been  our  constant  and  painstaking  assistant  in 
all  the  researches  with  which  this  little  book  is  con- 
cerned, we  have  examined  193  gunshot  fractures  of 
the  cranium.  There  were  well-marked  bone  injuries 
in  the  greater  number  of  the  cases ;  we  have  noted 
in  the  parietal  and  occipital  regions  a  loss  of  substance 


808  FRACTURES  OF  THE  ORBIT 

over  a  surface  larger  than  a  crown-piece ;  often  the 
bullet  had  traversed  the  cranium  from  side  to  side, 
that  is  to  say,  the  traumatism  had  fulfilled  ail  the 
conditions  necessary  for  the  apphcations  of  Pascal's 
law,  and  yet  never — we  repeat,  never — has  the  patient 
presented  the  least  evidence  of  injury  about  the  optic 
foramen  or  the  sphenoidal  fissure.  Not  a  motor 
paralysis  J  not  a  sensory  paralysis,  not  an  atrophy  of 
the  optic  nerve,  has  resulted  from  the  mischief  in  the 
bony  box  of  the  cranium.  As  clinical  observei*s,  we 
are  therefore  perfectly  entitled  to  affirm  that  gun- 
shot fractures  of  the  cranial  vault  are  not  accompanied 
by  either  fracture  or  radiation,  or  by  fracture  by 
contre-coup,  such  as  to  implicate  the  orbital  roof  and 
the  optic  foramen. 

We  do  not  deny  the  existence  of  fracture  by  radia- 
tion as  they  were  deserfbed  long  ago  by  Aran,  and 
afterwards  by  all  those  who  have  studied  the  pathology 
of  fractures  of  the  skull  (Felizet,  Ghipault  and 
Braquehaye,  etc.);  futi:her,  we  do  not  deny  frac- 
tures by  contre-coup  ("independent,"  Tr^lat),  that 
is  to  say,  those  which,  interrupted  for  a  moment  in 
their  course,  continue  in  the  Oirbital  vault  the  line  of 
fracture  of  the  cranial  vault ;  but  we  do  affirm  that 
these  fractures  are  the  cohsequence  of  falls  upon  the 
head,  of  violence  to  the  skull  produced  by  blunt 
bodies,  and  that  they  do  not  follow  gunshot  injuries. 
From  this  point  of  view  it  will  be  well  to  quote  the 
authorities  here  and  to  interpret  them ;  we  shall  see 
that  the  clinical  facts  and  experiments  are  not  in 
disagreement  with  our  point  of  view. 

If  we  read  attentively  the  excellent  article  by 
RoLLET  upon  fractures  of  the  orbit  in  the  Encydop^die 
d'Ophtalmologie  (Vol.  VIII,  p.  375  et  seq.),  we  see,  in 
fact,  that  the  fractures  radiated  from  the  vault  to  the 
base  are  due  to  falls  on  the  vertex.  These  radiations 
to  the  orbital  vault  are  very  common  (23  out  of  68 
cases,  Prescot-Hewett  ;  79  out  of  86  cases,  De 
Holder)  ;  but  in  these  cases,  when  one  is  dealing  with 
gun-shot  fractures,  it  is  a  question  of  suicide,  and  under 


GENERAL  CONSIDERATIONS  809 

these  circumstances  the  orbit  is  necessarily  impli- 
cated. Suicides  fire  a  bullet  into  the  mouth,  or  under 
the  chin,  or  in  a  region  adjoining  the  orbit,  so  that  a 
fissure  of  the  orbit  is  produced  by  direct  shock.  The 
same  applies  to  the  case  quoted  by  Rollet,  of  assas- 
sination by  the  blow  of  a  spade  on  the  orbital  region. 
Here  it  was  not  a  question  of  fracture  of  the  cranium 
propagated  to  the  orbit,  but  of  a  fracture  of  the  orbit 
spreading  to  the  cranium.  In  examining  the  79  cases 
of  fissure  of  the  orbit  cited  by  De  Holder,  we  find 
53  cases  of  fracture  of  the  optic  foramen ;  of  these  53 
cases,  42  are  fractures  from  gunshot ;  but  in  these 
42  cases,  32  are  shots  fired  into  the  mouth,  and  10 
into  the  temple  and  forehead.  These  are  evidently 
not  radiated  fractures,  but  direct  fractures  of  the 
orbital  vault ;  in  the  10  other  cases  it  was  a  question 
of  a  fall,  or  of  a  crushing  blow.  It  is  very  evident 
that  De  Holder's  statistics  in  no  way  contradict  our 
opinion,  which  is,  that  fractures  of  the  cranial  vault 
do  not  secondarily  affect  the  orbital  vault  by  radia- 
tion or  by  contre-coup ;  orbital  fractures  are  direct, 
or  do  not  occur  at  all. 

Let  us  see  what  the  authorities  in  military  surgery 
say. 

Chauvel  and  Nimier  write  :  "  Besides  these  direct 
fractures,  the  orbital  vaults  are  sometimes  implicated 
by  fissures  radiating  from  a  fracture  of  the  cranial 
vault;  we  may  even  observe  there  true  fractures  at 
a  distance  and  by  contre-coup  "  {Chirurgie  d'armee, 
p.  336).  They  are  speaking,  however,  in  a  general 
manner ;  they  nowhere  say  that  gunshot  fractures  of 
the  cranium  radiate  over  the  roof  of  the  orbit ;  on 
the  contrary  (p.  294  et  seq.)  they  write  that  "  in  crania 
fractured  by  projectiles  the  fissures  are  parallel  to 
the  direction  of  the  violence,  that  is  to  say,  antero- 
posterior in  fronto -occipital  shots,  transverse  when  the 
projectile  has  passed  from  one  temple  to  the  other; 
when  the  wound  is  frontal,  the  two  superior  fissures 
on  each  side  run  horizontally  from  front  to  back  and 
tend  to  rejoin  at  the  occiput,  thus  circumscribing  the 


810  FRACTURES  OF  THE  ORBIT 

skull-cap  by  a  circular  fissure  ;  the  two  oblique  branches 
below  and  behind  join  the  temporal  fossa  towards  the 
base  of  the  petrous  portion ;  these  fissures  tend  to 
detach  the  cranium  from  the  bony  mass  of  the  face. 
In  transverse  gunshots,  we  again  find  the  circular 
fissure,  which  instead  of  detaching  the  superior  part 
of  the  bony  vault  from  the  inferior,  seems  to  prefer 
to  divide  the  cranium  into  two  portions,  anterior  and 
posterior." 

Chauvel  and  Nimier  nowhere  mention  fissures 
radiating  from  the  cranial  vault  to  the  orbit. 

Delorme  writes  :  -"In  bi-temporal,  bi -parietal,  and 
bi-occipital  perforations,  we  sometimes  see  fissured 
radiations  towards  the  base,  but  they  are  relatively 
rare.  The  fissures  have  a  tendency  to  take  the 
circular  direction  rather  than  the  vertical  "  {Traite  de 
Chirurgie  de  guerre,  Vol.  II,  p.  547);  and  further,  on 
p.  553,  Delorme  says  again,  concerning  indirect 
fractures  or  those  by  contre-coup,  that  "  of  a  large 
number  of  crania  which  we  have  opened  after  having 
fractured  or  perforated  them  by  projectiles,  we  have 
not  been  able  to  discover  one." 

The  assertion  which  we  have  made  on  the  other 
side,  and  which  at  first  might  have  caused  surprise, 
is  therefore  quite  in  accord  with  classic  findings, 
whether  they  belong  to  the  clinical  or  experimental 
order ;  and  we  might  write  here  this  aphorism  : 
"  Gunshot  fractures  of  the  cranial  vault  lead  neither 
to  fractures  radiating  into  the  orbital  roof  nor  to 
fractures  by  contre-coup." 

Fractures  of  the  orbital  vault  and  of  the  optic 
canal,  when  they  are  produced  by  radiation,  are  the 
result  of  falls  on  or  violent  contusions  of  the  vertex ; 
more  often  they  result  from  direct  blows  in  the  region 
of  the  orbit ;  gunshot  of  the  forehead,  contusion  of 
the  superciliary  arch,  fractures  by  telescoping,  due  to 
a  fall  upon  the  feet. 

The  aetiology  and  pathology  of  direct  fractures  need 
not  detain  us  long ;  one  expects  to  find  that  gunshot 
wounds  often  affect  the  circumference  of  the  orbit  and 


GENERAL  CONSIDERATIONS  811 

its  walls ;  we  note  the  possibility,  arid  even  the  rela- 
tive frequency  and  gravity,  of  isolated  fractures  of 
the  superior  wall  with  integrity  of -the  margin.  The 
margin,  thanks  to  the  arrangement  we  have  pointed 
out  above  (Fig.  2),  has  resisted,  but  the  orbital  vault, 
extremely  thin,  has  yielded  to  the  influence  of  the 
oscillatory  vibrations  imparted  to  neighbouring  tissues 
by  the  violence  of  the  blow.  Grave  accidents  are  to  be 
anticipated  to  the  optic  foramen  (atrophy  of  the  nerve), 
and  on  the  side  of  the  brain  (meningo -encephalitis), 
as  a  consequence  of  these  latent  fractures. 

The  projectile  which  smashes  the  superior  border  of 
the  orbit  often  implicates  the  frontal  sinus.  Legouest 
has  reported  the  case  of  an  officer  who  carried  a  bullet 
for  eighteen  years  in  this  sinus,  when  it  fell  spontane- 
ously into  the  pharynx. 

The  internal  wall  of  the  orbit  is  more  fragile;  it  is 
easily  perforated,  even  by  small  missiles.  We  have 
seen  fragments  of  grenade  perforate  the  os  planum 
and  lodge  in  the  ethmoid,  where,  moreover,  they  are 
often  well  tolerated. 

One  of  the  most  frequent  amongst  the  injuries  of 
war  is  that  which  affects  the  malar  bone.  It  may  be 
carried  away  by  a  bullet  or  crushed  by  a  shell  frag- 
ment. In  a  case  of  Delorme's,  a  bullet  struck 
obliquely  the  infero -external  angle  of  the  orbit  and 
loosened  a  corner  of  the  bone.  Very  often  the  bullet 
or  shell  fragment  does  away  with  the  malar  bone, 
destroys  the  eye,  and  in  passing  out  leaves  a  notch  in 
the  supra -orbital  arch. 

Fracture  of  the  external  wall  of  the  orbit  is,  par 
excellence,  that  which  results  from  attempts  at  suicide  ; 
it  has,  however,  not  been  rare  in  our  experience,  and 
reports  will  be  found  later.  Sometimes  a  bullet  per- 
forates the  two  orbits  and  severs  or  destroys  both  optic 
nerves  without  touching  the  eyes.  In  several  of  our 
cases  the  bullet  has  entered  near  the  tragus,  traversed 
the  orbit  from  behind  forwards,  from  without  inwards, 
and  from  below  upwards,  severing  the  optic  nerve  and 
emerging  at  the  root  of  the  nose. 


812  FRACTURES  OF  THE  ORBIT 

Fig.  35  gives  the  ophthalmoscopic  appearance  in  an 
old  avulsion  of  the  optic  nerve,  as  well  as  Fig.  1, 
Plate  III. 

If  we  wished  to  enlarge  upon  the  aetiology  of  these 
fractures  of  the  orbit,  we  should  only  have  to  take 
one  by  one  the  cases  cited  later  and  expatiate  on  their 
peculiarities.  Perusal  of  the  case  reports  and  the 
examination  of  the  tables  which  accompany  them  will 
suffice. 

Moreover,  the  pathology  of  the  conditions  resulting 
from  direct  fracture  of  the  circumference  and  walls  of 
the  orbit  is  only  interesting  so  far  as  it  concerns  the 
injuries  to  the  orbital  contents  (including  the  eye). 
Lesions  of  the  skeleton  evidently  depend  upon  the 
propulsive  force  of  the  wounding  agent,  its  mass  and 
its  form ;  they  depend  also  upon  the  point  struck ; 
when  the  projectile  meets  the  malar  bone,  as  very 
frequently  happens,  it  causes  a  comminuted  fracture 
of  that  bone  and  often  lodges  in  its  substance.  There 
are  no  radiated  fractures,  because  the  ptery  go -maxillary 
fissure  checks  the  course  of  the  fracture ;  on  the  other 
hand,  when  the  wounding  agent  strikes  the  frontal 
bone  at  the  level  of  the  superior  orbital  margin,  the 
violent  contusion  of  this  bone  is  accompanied  by  a 
fracture  of  the  orbital  vault  spreading  to  the  sphenoidal 
fissure  and  the  optic  foramen,  implicating  the  very 
important  organs  found  in  this  neighbourhood. 

If  the  reader  will  add  to  these  considerations  what 
has  been  said  above  on  the  subject  of  the  resistance 
of  the  orbit  to  traumatism,  he  will  be  in  possession  of 
all  that  concerns  the  pathogenesis  of  fractures ;  what 
remains  to  be  said  will  be  more  appropriate  when  we 
come  to  speak  of  the  various  visual  troubles  which 
these  fractures  provoke. 


CHAPTER  IV 

FRACTURES  OF  THE  ORBIT 
WITH  PRESERVATION  OF  THE  EYEBALL 

We  shall  divide  the  fractures  of  the  orbit,  from  the 
point  of  view  of  their  effects  on  the  visual  apparatus, 
into  two  great  classes — 

I. — Those  in  which  the  globe  is  preserved. 
II. — Those  in  which  the  globe  is  destroyed. 

We  shall  commence  by  speaking  of  the  first,  and  we 
shall  place  immediately  before  the  reader  the  chief 
data,  viz.  the  principal  clinical  demonstrations  gained 
from  our  experience. 

§  I.— The  Laws  Governing  the  Affections  of  the 
Visual  Apparatus  in  Injuries  of  the  Orbit  with 
Preservation  of  the  Eyeball 

(1)  When  the  projectile  passes  above  the  orbit, 
implicating  the  frontal  bone  and  the  anterior  cerebral 
region,  it  produces  fractures  of  the  orbital  vault 
affecting  the  sensory,  motor,  and  optic  nerves  in  the 
region  of  the  optic  foramen  and  the  sphenoidal  fissure. 
The  eyeball  is  not  involved. 

(2)  When  the  projectile  passes  below  the  eyeball 
without  traversing  the  orbit  and  without  fracturing 
it,  it  produces  concussion  affecting  the  eye  in  the 
macular  region.  This  is  the  great  cause  of  diminution 
or  loss  of  acuity  of  central  vision. 

(3)  When  the  projectile  has  fractured  the  orbit, 
crushing  in  the  wall  more  or  less,  without  touching 
the  eyeball,  it  produces  in  the  globe  grave  concussion 

'813 


814  FRACTURES  OF  THE  ORBIT 

injuries,  macular  lesions  and  choroidal  ruptures. 
Macular  lesions  occur,  irrespective  of  the  wall  damaged, 
whether  external,  internal,  or  inferior. 

(4)  When  the  projectile  has  traversed  the  orlDit 
without  touching  the  eyeball,  it  produces  the  same 
disorders  together  with  those  which  result  from  the 
laceration  of  the  organs  contained  in  the  orbital  cavity. 
The  optic  nerve  is  often  divided ;  the  papilla  is  then 
lacerated  as  if  torn  away. 

(5)  When  the  projectile  grazes  the  eyeball  tangen- 
tially,  without  rupturing  it,  or  when  the  globe  is 
touched  by  the  orbital  wall  being  driven  in  upon  it, 
it  causes  damage  in  immediate  relationship  with  the 
bruised  point  (choroido -retinal  lacerations  with  detach- 
ment of  the  retina  and  retinitis  proliferans) ;  the 
macular  region  is  often  involved  in  the  damage,  but 
it  is  not  injured  alone. 

If  these  laws  were  based  only  on  theoretical  con- 
siderations they  would  certainly  be  ill-founded,  but 
they  rest  on  the  study  of  cases,  upon  clinical  evidence, 
and  it  is  for  this  reason  that  we  desire  to  make  them 
known. 

The  case -reports  are  divided  into  two  categories  : — 
First  Category. — Fractures  of  the  orbit  with  preserva- 
tion of  the  eye,  without  retention  of  a  foreign  body. 

Second  Category. — Fractures  of  the  orbit  with  pre- 
servation of  the  eye,  with  retention  of  a  foreign  body. 

First  Category 

The  first  category  of  case -reports  is  divided  into  five 
groups. 

First  Group 

Fracture  of  right  orbit  by  rifle  bullet.     (Case  1 .) 

C.  T.,  Cavalry,  wounded  May  10,  1915,  at  L.  A  rifle- 
bullet  had  penetrated  the  left  supra-orbital  region,  at  1  cm. 
from  the  end  of  the  eyebrow,  and  emerged  from  the  right 
supra-orbital  region  near  the  temporal  fossa,  2  cms.  in  front 


PRESERVATION  OF  THE  EYEBALL  815 

of  the  temporo-maxillary  articulation  (Fig.  4).  T.  lost 
consciousness  for  twenty  four  hours  and  was  trephined  the 
next  day. 

Condition  on  admission,  Jan,  15,  1916.  The  aperture 
of  entrance  of  the  projectile  is  extremely  painful  to  the 
touch.  The  zone  of  emergence  is  very  excavated,  like  a 
cupola;  at  this  point  there  is  depression  of  the  bones, 
frontal  and  temporal,  near  the  suture  between  the  two 
bones,  a  little  behind  the  external  orbital  process.  No 
cerebral  pulsation. 

There  is  a  fracture  of  the  right  superior  orbital  margin. 


Fig.  4. 

the  seat  of  a  large  notch,  and  there  is  visible  here  a  sinus 
from  which  purulent  liquid  wells  up. . 

The  right  upper  lid  has  ectropion ;  closure  of  the  eyelids 
is  almost  impossible  because  of  this  vicious  cicatrix.  No 
defect  of  movement  to  the  right  or  left. 

Hypersesthesia  of  nasal,  frontal  and  lacrymal  nerves 
is  to  be  noted  on  the  right  side;  they  have  all  probably 
been  implicated  in  the  traumatism  propagated  to  the 
sphenoidal  fissure. 

No  lesion  of  the  eyeball ;  median  and  deep  membranes 
are  intact. 

R.  and  L.         V  =  9/10. 

The  central  and  peripheral  nervous  system  is  normal; 
no  meningeal  reaction. 


81G 


FRACTURES  OF  THE  ORBIT 


Fracture  of  the  superior  wall  of  the  left  orbit  and  frontal  sinus 
by  shell  fragment.     (Case  2.) 

R.  M.,  Infantry,  wounded  May  4,  1916,  at  V.;  shell 
wound  left  superior  orbital  region.  Trephined  May  6, 
at  Saint-Dizier,  with  extraction  of  bone  splinters.  Slow 
recovery  owing  to  suppuration.     (Fig.  5.) 

Condition  on  admission,  June  15,  1916.  There  is  an 
incision  about  3  cm.  long  at  the  level  of  the  superior 
margin  of  the  left  orbit,  parallel  with  the  superciliary 
arch.  Another  cicatrix  is  to  be  seen  at  right  angles  to 
this  arch  meeting  the  first  incision  at  its  external  third. 


Fig.  5. 

This  cicatrix,  not  painful,  is  the  seat  of  a  slight  depres- 
sion following  fracture  of  the  subjacent  layer  of  bone ; 
no  cerebral  pulsation  perceived. 

Radiogram  confirms  fracture  of  the  superior  orbital 
margin. 

There  is  insensibility  of  the  left  frontal  region  following 
section  of  filaments  of  the  frontal  nerve. 

The  left  eye  is  absolutely  intact ;  no  lesion  of  the  media 
or  of  the  choroid  or  retina. 

L.  E.  with  +  1  D  cyl.  axis  90°,  V  =  5/10. 
R.  E.         V=  I. 

Diminished  acuity  of  vision  in  left  eye,  explicable  by 
injury  to  optic  nerve  in  its  bony  canal. 


PRESERVATION  OF  THE  EYEBALL         817 

Fracture  of  the  righi  superior  orbital  margin  with  consecutive 
atrophy  of  the  optic  nerve.     (Case  3.) 

A.  G.,  Infantry,  wounded  May  10,  1916,  by  grenade 
explosion,  in  the  right  supra-orbital  region.  Fragment 
extracted  at  B.  On  admission,  Sep,  3,  1916,  there  was 
a  cicatrix  1  cm.  long  in  the  middle  of  the  right  eyebrow. 
Palpation  of  the  superior  orbital,  margin  reveals  a  notch 
in  the  bone,  admitting  the  tip  of  the  index  finger;  no 
foreign  body  to  be  felt.  The  patient  found  almost  im- 
mediately that  he  could  not  see  with  the  right  eye. 

This  eye  has  slight  external  strabismus  following  the 
amblyopia ;  it  is  normal  outwardly .  No  extrinsic  muscular 
paralysis  ;  the  dilated  pupil  is  insensible  to  natural  stimuli. 
The  consensual  reflex  from  right  to  left  is  abolished,  but 
persists  from  left  to  right.  No  injury  to  transparent 
media.  The  optic  disc  is  the  seat  of  complete  white 
atrophy. 

R.  E.        V-0. 

The  left  ej^e  had  suffered  from  a  foreign  body  in  the 
cornea,  which  had  been  extracted  at  B. 

L.  E.,  with  -h  0-5  D  cyl.  axis  0       V  =-  7/10. 

Second  Group 

Fracture  of  both  orbits  by  bullets.    (Case  4.) 

A.  R.,  Infantry,  wounded  Jan.  11,  1916,  by«a  bullet  fired 
from  a  distance  of  about  eighty  metres. 

Leaving  the  military  hospital  at  Chalons,  Jan.  14,  he 
entered  our  hospital  on  Feb.  23. 

Condition. — ^The  buUet  had  penetrated  near  the  inferior 
border  of  the  left  orbit,  quite  near  the  inner  inferior 
angle,  in  the  lacrymal  region,  and  came  out  near  the  right 
zygomatic  arch,  3  cm.  in  front  of  the  tragus.  It  had  there- 
fore traversed  the  nasal  fossae.  At  the  aperture  of  exit 
there  is  to  be  felt  a  cicatrix  adherent  to  the  subjacent  bone. 

Examination  of  the  nose  shows  a  transfixion  wound  with 
intra-nasal  adhesions. 

The  tip  of  tne  index  finger  detects,  by  the  inferior 
external  angle,  a  crack  in  the  floor  of  the  left  orbit,  a  crack 
which  appears  to  be  prolonged  far  backwards.  On  the 
internal  wall  of  the  right  orbit  is  an  exostosis  which  impedes 
deep  palpation  cf  the  cavity. 


818 


FRACTURES  OF  THE  ORBIT 


Ocular  Examination. — The  right  eye,  visual  acuity  =  0, 
is  outwardly  normal.  At  the  posterior  pole  is  a  large 
choroido-retinal  rupture  (concussion  lesion);  the  whole  of 
the  papillo-macular  region  is  the  seat  of  patches  of  choroido- 
retinitis,  pigmented  and  proliferating,  secondary  to  hsemor 
rhage  into  the  deep  membranes  (Plate  III,  Fig.  3). 

The  lower  eyelid,  slightly  oedematous,  is  in  a  state  of 
cicatricial  ectropion  at  the  inner  angle. 

The  left  eye  is  normal. 

L.  E.        V=  10/10. 
No    injury    to    the    transparent    media    or    the    deep 


Fig.  6. 


membranes.     At    the  aperture   of    entrance  suppuration 
from  bone  persists  :  some  sequestra  have  been  eliminated. 
Condition  stationary,  June  20,  1916. 

Fracture  of  both  orbits  by  rifle-bullet;  haemorrhage  into  the 
vitreous  body  R.  £. ;   macular  choroiditis  L.  E.    (Case  5.) 

L.  M.,  Infantry,  wounded  Sep.  25,  1915,  at  S.,  by  a  rifle 
bullet,  which  traversed  the  facial  bones  from  side  to  side. 
He  did  not  lose  consciousness.     Admitted  Sep.  27. 

The  bullet  penetrated  at  the  level  of  the  zygomatic  arch 
of  the  left  side,  about  5  cm,  from  the  external  auditory 
meatus  and  3  cm.  from  the  orbital  margin.     The  orifice 


PRESERVATION  OF  THE  EYEBALL 


819 


of  exit  is  a  little  below  the  right  orbital  margin,  near  the 
external  angle  of  that  orbit  (Fig.  7). 

Its  course  is  therefore  from  left  to  right,  and  slightly 
from  below  upwards.  In  its  course  the  projectile  has 
fractured  the  floor  of  the  left  orbit,  the  nasal  fossae,  the 
internal  wall  of  the  right  orbit,  and  traversed  the  cavity 
in  its  lower  part. 

On  admission  no  exophthalmos  could  be  noticed. 

The  ocular  lesions  which  L.  presented  are  as  follow — 

R.  E. — The  vitreous  body  is  the  seat  of  a  profuse  haemor- 
rhage,  preventing  any  red   reflex.     Little   by  little   this 


Fig.  7. 


haemorrhage  became  absorbed,  and  by  April  4,  1916  there 
were — 

(1)  Large  patches  of  whitish  choroido-retinitis,  star- 
shaped,  in  the  macular  region  (concussion  injuries). 

(2)  Large  fibrous  bands  covering  the  optic  disc,  which 
is  invisible  to  the  ophthalmoscope  (retinitis  proliferans). 

(3)  Atrophy,  with  some  pigmented  foci  disseminated 
about  the  inferior  region  of  the  retina  and  choroid,  in  the 
track  of  the  bullet  (contact  lesions). 

R.  E.         V  =  0. 

The  eye  has  slight  external  squint. 

L.  E. — Sep.  27,  the  visual  acuity  of  this  eye  was  3/10 
barely. 


820  FRACTURES  OF   THF,   ORBIT 

Transparent  media  are  intact.  There  is  a  cherry-red 
coloration  extending  over  the  whole  macular  field  (con- 
cussion lesion),  and  a  sprinkling  of  choroido-retinitis  at  the 
lower  part. 

April  4,  1916,  on  his  discharge,  the  acuity  of  this  eye  had 
slightly  diminished. 

L.  E.        V  -  2/10  barely. 

Bullet  traversing  the  face,  bilateral  macular  haBmorrhage. 

(Case  6.) 

M.  R.,  Infantry,  wounded  March  12,  1916.  Admitted 
May  13,  from  Chaumont,  via  Orleans. 


Fig.  8. 

Examination. — A  lifle  bullet,  from  about  150  metres, 
had  penetrated  the  left  masseteric  region,  3  cm.  below  the 
middle  of  the  zygomatic  arch  and  2  cm.  in  front  of  the 
superior  insertion  of  the  lobule  of  the  ear,  in  the  interval 
comprised  between  the  ascending  ramus  of  the  inferior 
maxilla  and  the  coronoid  process. 

The  orifice  of  exit,  represented  by  a  star-shaped  cicatrix, 
adherent  to  the  underlying  fractured  bone,  is  situated  4  cm. 
below  the  external  angle  of  the  right  orbit  and  7  cm.  in 
front  of  the  lobule  of  the  right  ear.  The  projectile  has 
therefore  traversed  the  face  in  a  slightly  oblique  direction, 
from  behind  forwards  and  from  left  to  right. 


PRESERVATION  OF   THE  EYEBALL  821 

Palpation  reveals  on  the  right  orbital  margin,  exactly 
in  its  middle,  a  loss  of  bone  substance  forming  a  notch  of 
about  1  cm.  (Fig.  8). 

Examination  of  the  Eyes. — R.  E. — The  eye  is  outwardly 
normal;  no  opacities  in  the  media.  The  ophthalmoscope 
reveals  a  haemorrhage  of  the  macular  region  (concussion 
lesion),  without  other  lesions  of  retina  or  choroid.  Disc 
intact.  ,  The  visual  field  shows  the  existence  of  an  absolute 
central  scotoma. 

R.  E.         V  -  1/50. 

L.  E. — Similar  integrity  of  the  transparent  media  and 
the  deep  membranes,  except  in  the  macular  region,  the  seat 
of  a  slight  haemorrhage,  cherry-red  in  colour  (concussion 
lesion).  The  perimetric  examination  shows  the  presence  of 
a  relative  scotoma, 

L.  E.        V  -  3/10. 

Third  Group 

Fracture  of  the  right  orbit  by  a  bullet,  laceration  of  the  choroid  ; 
optic  atrophy,  R.  E.    (Case  7.) 

F.  M.,  Infantry,  wounded  Oct.  31,  1914,  near  S. 
(Marne),  by  a  rifle  bullet.  From  Chalons  he  was  sent  to 
the  Complementary  Hospital  No.  18  at  Bordeaux,  where  he 
was  admitted  Dec.  4,  1914. 

Condition. — The  projectile  entered  the  cheek  on  the  left 
side,  three  fingers'  breadth  in  front  of  the  angle  of  the  man- 
dible, one  finger's  breadth  above  the  lower  border  of  the 
same  bone.  It  divided  the  alveolar  border  of  the  maxilla, 
breaking  the  premolar  and  two  molars ;  it  crossed  the  mouth, 
sligjitly  wounded  the  dorsum  of  the  tongue,  perforated  the 
palatine  arch  near  the  median  line,  traversed  the  right  nasal 
fossa  and  the  right  antrum,  smashing  in  the  floor  of  the 
orbit,  and  came  out  in  the  temporal  fossa,  near  the  orbital 
margin,  at  the  level  of  the  angle  made  by  the  malar  bone 
with  the  external  angular  process  of  the  frontal  bone 
(Fig.  9).  The  bullet  passed  beneath  and  behind  the  eye 
without  touching  it. 

At  the  time  of  our  examination  the  right  eye  was  ipTop- 
tosed;  it  deviated  downwards  and  outwards,  but  there 
was  no  diplopia  because  of  the  low  visual  acuity  of  the  eye. 


822 


FRACTURES  OF  THE  ORBIT 


No  lesions  of  the  anterior  segment  or  the  appendages  of 
the  eye  were  remarked. 

The  vision  of  this  eye  is  quantitative.  In  the  macular 
region  there  is  to  be  seen  a  vast  laceration  of  the  choroid, 
extending  by  an  arciform  prolongation  beneath  the  disc 
and  resulting  from  concussion  transmitted  to  the  posterior 
pole  of  the  eye.  The  optic  nerve  is  in  a  fair  way  to  almost 
complete  white  atrophy. 

The  visual  field  is  not  measurable. 


Fro.  9. 


The  left  eye  is  normal.  Acuity  equals  7/10  and  the 
visual  field  is  lessened  by  10°  in  all  directions. 

M.  intermittently  removes  pus  from  the  right  nostril ; 
there  is  a  deviation  of  the  septum  to  the  right  and  a 
thickening  to  the  left,  resulting  from  the  seton-like  wound. 

He  was  discharged  Feb,  12,  1915,  in  the  same  condition. 

Wound  of  the  facial  bones  by  rifle  bullet ;    macular  and 
peripheral  choroido-retinitis,  R.  E.    (Case  8.) 

J.  D.,  Sergeant,  Infantry,  wounded  bv  rifle  bullet, 
Nov.  3,  1915,  at  M.  * 

The  bullet,  fired  at  close  quarters,  penetrated  1  cm.  above 
the  left  zygomatic  arch,  and  came  out  at  the  middle  portion 
of  the  inferior  orbital  margin,  where  a  dej^ression  exists  in 
the  bone  in  which  one  could  phice  the  tip  of  the  index  finger 


PRESERVATION  OF  THE  EYEBALL 


82 '3 


(fracture  of  right  orbital  margin).  At  the  level  of  the  velum 
palati  the  orifices  of  entry  and  exit  of  the  projectile  are 
visible  as  it  emerged  from  the  facial  mass.     (Fig.  10.^ 

Condition. — The  wound  was  cicatrised  when  we  examined 
D.,  who  complained  that  he  could  no  longer  see  with  the 
right  eye. 

This  eye  presented  the  following  lesions,  which  are  indi- 
rect, by  contre-coup,  by  concussion,  the  projectile  not 
having  touched  the  eyeball. 


Fig.  10. 


In  the  macular  region  there  is  a  greyish  white  discolora- 
tion with  pigmented  spots,  explaining  the  feebleness  of 
visual  acuity. 


R.  E. 


V-  1/100. 


The  visual  field  shows  loss  of  central  vision  and  defect 
in  the  superior  peripheral  field. 

In  the  lower  and  outer  part,  i.  e.,  in  relation  with  the 
aperture  of  exit  of  the  projectile,  the  retina  and  choroid 
are  greatly  disturbed ;  laceration  of  the  choroid  with  large 
patches  of  white  atrophy  and  pigmented  foci,  probably 
secondary  to  a  haemorrhage  en  nappe  of  the  deep  mem- 
branes (contact  lesions).     (Plate  I.  Fig.  3.) 

The  left  eye  is  intact,  and  its  visual  acuity  normal. 

At  the  end   of  three   months  the   condition  remained 


824  FRACTURES  OF   THE  ORBIT 

stationary,  and  it  is  probable  that  these  affections  undergo 
little  change. 

Fracture  of  the  external  wall  of  the  right  orbit ;   macular 
choroido-retinitis  ;    avulsion  of  optic  nerve.    (Case  9.) 

J.  L.,  Infantry,  wounded  at  the  Dardanelles,  transported 
unconscious  in  hospital  ship  :  he  ^^  ent  to  Egypt  and  thence 
to  Marseilles. 

Condition. — From  the  inferior  external  part  of  the  right 
lower  eyelid  there  commences  a  non-adherent  arciform 
cicatrix,  which  passes  4  cm.  behind  the  extremity  of  the 
eyebrow  and  is  directed  towards  the  upper  portion  of  the 
temporal  region.  In  the  median  portion  of  the  wound  is  to 
be  felt  a  little  bony  depression,  which  leads  to  an  extensive 
fracture  of  the  outer  wall  of  the  orbit,  most  marked  above 
and  behind,  due  to  driving  in  of  the  orbital  wall. 

The  right  eye  is  outwardl}^  normal.  The  pupil  is  slightly 
deformed  because  of  a  leucoma  adhaerens  down  and  in. 
The  vision  of  this  eye  =  0.  There  are  floating  opacities  in 
the  vitreous,  but  the  lens  has  preserved  its  physiological 
trans  j)arency. 

The  deeper  membranes  are  the  seat  of  serious  damage. 

In  the  papillo-macular  region,  in  place  of  the  papilla 
there  is  a  large  atrophic  zone,  with,  in  the  centre,  a  tinge  of- 
seagreen  which  seems  to  be  due  to  a  light  fibrinous  organised 
clot.  The  disc  has  disappeared  under  the  mass  of  retinitis 
proliferans.  There  is  also  a  narrow  elongated  laceration, 
somewhat  arched,  yellowish  in  colour,  situated  slightly 
below  the  macular  region. 

Tho  globe  has  normal  tension.  Radiography  has  given 
a  negative  result  as  regards  the  possible  presence  of  intra- 
orbital foreign  bodies. 

The  left  eye  is  normal. 

Condition  remained  stationary  until  discharge  from  hos- 
pital, April  22,  1916. 

Dec.  10,  1916,  we  again  examined  this  case  \vith  the 
ophthalmoscope.  The  fundus  of  the  eye,  less  encumbered 
bv  exudation,  presented  the  condition  y.hown  in  detail  in 
Plate  III,  Fig.  1. 

It  is  a  perfect  tvpe  of  avulsion  of  the  optic  nerve 
(Plate  III,  Fig.  1).   "^ 


PRESERVATION  OF  THE  EYEBALL         825 

Fracture  of  the  external  wall  of  the  left  orbit  by  rifle  bullet ; 
traumatic  choroido-retinitis,  L.  E.    (Case  10.) 

R.  D.,  Sergeant,  Infantry,  wounded  April  25,  1915,  at 
E.  A  rifle  bullet  had  wounded  the  left  external  orbital 
region.  The  projectile  had  struck  the  lower  and  outer  part 
of  the  left  orbit  and  had  come  out  a  little  in  front  of  the 
left  temporo-maxillary  articulation.  In  its  course  it  had 
fractured  the  zygomatic  process  and  the  external  waU  of 
the  left  orbit. 

On  admission,  a  large  furrow,  very  deep,  is  seen  on  the 
left  cheek;  the  cicatricial  tissue  adheres  firrdly  to  the 
underlying  tissues. 

Paralysis  of  the  filaments  of  the  facial  nerve  going  to  the 
orbicularis  iirferior  was  noted,  whence  a  slight  ectropion 
of  the  lower  eyelid  and  lagophthalmos. 

No  disturbance  of  sensation. 

Radiography  yielded  a  negative  result,  both  as  to  the 
possible  presence  of  splinters  and  the  nature  of  the  fracture. 

The  eyeballs  are  normal  exteriorly.  Visual  acuity 
R.  E.  =  10/10. 

In  the  left  eye  the  transparent  media  are  intact,  but  there 
are  grave  injuries  to  the  retina  and  choroid. 

(1)  In  the  region  of  the  macula,  an  extensive  cherry-red 
patch,  resembling  a  haemorrhage  and  giving  rise  to  a  central 
scotoma. 

(2)  In  the  superior  and  inferior  peri-macular  region, 
patches  of  atrophic  and  pigmented  choroido-retinitis,  secon- 
dary to  choroidal  haemorrhages. 

These  damaged  tissues  explain  the  feebleness  of  visual 
acuity,  which  is  1/50;  they  are  due  to  concussion  of  the 
region;  the  eye  has  not  been  touched. 

Feb.  4,  1916,  restoration  of  the  vicious  facial  cicatrix  was 
attempted  by  means  of  an  adipose  graft.  Results  excellent, 
and  the  case  was  discharged  as  a  convalescent,  April  3. 

Fourth  Group 

Fracture  of  the  orbit  by  a  shrapnell  ball ;  section  of  optic  nerve, 
neuro-paralytic  keratitis.    (Case  11.) 

H.  B.,  Lieut.,  Zouaves;  wounded  Sep.  23,  1914,  at  Tr. 
The  first-aid  dressing  was  applied  immediately  after  the 
injury,  and  reapplied  at  the  dressing  station.     This  officer 


826 


FRACTURES  OF  THE  ORBIT 


was  afterwards  sent  to  dompiegne,  thence  to  Angers  and 
Bordeaux,  where  he  arrived  Sep.  27. 

Condition. — He  was  struck  by  a  shrapnel  ball  at  the  mo- 
ment of  looking  out  of  the  trench.  Sensation  of  having  the 
eyeball  torn  out,  with  free  temporal  haemorrhage  and  slight 
epistaxis.  Le  medecin-major  de  Fambulance  diagnosed 
haematoma  of  the  orbit,  which  leads  one  to  suppose  that 
considerable  exophthalmos  existed  from  the  outset. 

The  wound  is  very  small,  like  a  bullet-wound;  it  is 
situated  at  the  superior  external  angle  of  the  left  orbital 


Fig.  11. 

opening.  There  is  marked  exophthalmos,  so  that  the  cornea 
cannot  be  protected,  closure  of  the  lids  being  impossible. 

The  cornea  is  quite  insensitive,  save  in  its  internal 
quadrant. 

The  pupil  is  dilated  and  immobile. 

Examination  of  the  fundus  of  the  eye  shows  the  typical 
picture  of  avulsion  of  the  optic  nerve;  papilla  invisible, 
covered  by  abundant  haemorrhage  which  extends  far  into 
the  neighbouring  retina  and  choroid ;  the  posterior  pole  pre- 
sents, moreover,  milky  white  coloration  due  to  traumatic 
retinal  oedema,  especially  in  the  macular  region. 

Radiographic  examination  shows  a  shrapnel-ball,  which 
after  having  crossed  the  left  orbit,  has  perforated  theos 


PRESERVATION  OF  THE  EYEBALL 


827 


planum,  traversed  the  nasal  fossae,  and  come  to  rest  in  the 
right  ethmoid,  very  near  the  partition  and  the  right  orbital 
cavity  (Figs.  11  and  12). 

In  the  days  following  the  appearance  of  a  neuro-paralytic 
keratitis  was  noted.  Under  the  influence  of  astringent 
dressings  the  corneal  ulceration  improved,  and  there  was 
diminution  of  conjunctival  chemosis  and  exophthalmos. 

On   Oct.   29,    1914,    extraction   of   the   projectile   was 
attempted.     Incision  outlining  the  wing  of  the  left  nostril, 
passing  along  the  nose  in  front  of  the  lacrymal  region; 
section  of  the  nasal  bone  by  bone-forceps.     The  septum  was 


found  to  be  much  distorted.  With  a  curette  the  track  of 
the  projectile  could  readily  be  traced,  and  it  was  easily 
extracted.     Sutures.     After-history  normal. 

Jan.  20,  1915.     Notes  on  discharge — 

L.  E. — Loss  of  vision,  consequent  on  section  of  the  optic 
nerve.  Mydriasis.  Very  slight  corneal  nebula.  Perfect 
preservation  of  the  globe  and  of  its  movements. 

R.  E. — Normal. 


Fracture  of  the  left  orbit  by  bullet,  section  of  left  optic  nerve  ; 
laceration  of  choroid,  L.  E.    Detachment  of  retina,  R.  E. 

(Case  12.) 

Y.  G.,  Algerian  Sergeant;  wounded  Aug.  23,   1914,  at 
0.,  by  rifle  bullet;   was  made  prisoner  on  26th.     Went  to 


828 


FRACTURES  OF  THE  ORBIT 


Charleroi  and  Diisseldorf.  Returned  as  seriously  wounded. 
G.  came  under  our  care  Dec.  3,  1914,  with  a  certificate 
attesting  the  seriousness  of  his  condition. 

Examination. — Injury  by  rifle  bullet  from  distance  of 
about  200  metres.  The  bullet  entered  the  right  cheek-bone 
and  emerged  from  the  left  temporal  fossa,  two  fingers' 
breadth  behind  the  orbital  arch.  The  projectile  has  not 
traversed  the  right  orbit;  it  has  broken  the  floor  at  the 
level  of  the  malar  bone  and  also  near  the  internal  angle  (two 
fractures),  traversed  the  nasal  fossae,  and  finally  left  the 
orbit  (Fig.  13). 


Fig.  13. 


In  its  course  it  has  caused  the  following  injuries  : — 
R.  E. — In  the  vitreous  there  are  numerous  floating 
bodies.  Below  and  to  the  outer  side  are  seen  an  extensive 
retinal  detachment  and  concussion  lesions  extending  to 
the  macula.  The  upper  part  of  the  visual  field  is  lost 
to  near  the  point  of  fixation. 

R.  E.,  with  +  1  D  sph.,  V  =  3/10  barely. 

L.  E. — ^The  left  optic  nerve  has  been  divided  by  the 
bullet;  it  is  in  a  state  of  complete  white  atrophy;  the 
vessels  are  normal.  There  is  also  a  rupture  of  the  choroid 
in  the  macular  region  with  pigmentary  deposit  between 
the  macula  and  the  disc. 


L.  E. 


V  =  0. 


PRESERVATION  OF   THE  EYEBALL         S2d 

These  injuries  are  produced  by  contusion  and  immediate 
pulling  on  the  left  eyeball  at  the  moment  of  injury. 

The  retinal  detachment  of  the  right  side  was  treated 
for  two  months  (rest,  compression,  NaCl,  etc.) ;  on  his 
discharge  it  was  still  present,  and  visual  acuitv  remained 
about  3/10. 

Fracture  of  both  orbits  ;  retinal  haemorrhage,  R.  E. ;  retinitis 
proliferans,  L.  E.    (Case  13.) 
A.  G.,  Corporal,  Infantry,  was  wounded  at  N.  O.  May  29, 
1915,  by  a  rifle  bullet  which  traversed  the  face.     Admitted' 
July  9,  1915. 


Fig.  14. 


Condition. — The  bullet  entered  by  the  left  temporal 
region  and  emerged  from  the  right  temporal  region.  The 
course,  slightly  oblifjue  from  left  to  right  and  from  above 
downwards,  passes  behind  the  external  orbital  margin, 
under  the  left  optic  nerve  at  the  level  of  the  posterior 
pole,  and  nearer  the  equator  when  passing  the  right  eye. 
The  projectile  has,  therefore,  caused  a  fracture  of  both 
orbits  (Fig.  14). 

In  the  right  e}'e  numerous  retinal  haemorrhages  in  the 
lower  part  are  to  be  seen,  corresponding  to  a  partial  loss 
of  the  upper  part  of  the  visual  field.  Macular  and  para- 
macular lesions  from  concussions ;   right  eye  not  touched. 


830 


FRACTURES  OF   THE  ORBIT 


On  the  left  side,  numerous  tracts  of  proliferating  retinitis. 
In  addition  there  are  little  hsemorrhagic  patches  to  the 
outer  side  and  below.  In  the  vitreous  are  numerous 
flocculi;   left  eye  probably  touched. 

The  visual  field  is  the  seat  of  an  extensive  central 
scotoma. 

R.  E.        V  =  1/10. 
L.  E.        V  =  1/200. 

G.  has  great  difficulty  in  opening  his  mouth,  due  to  a 
lesion  of  the  temporal  muscles.     There  is  anaesthesia  of 


Fig.  15. 

both  infra-orbital  nerves  extending  to  the  lower  eyelid, 
the  ala  of  the  nose  and  the  upper  lip,  more  marked  on  the 
left  side.  He  left  hospital  July  22,  1915;  state  of  both 
eyes  as  on  July  10. 

Fracture  of  right  orbit,  shell  wound  ;  rupture  of  choroid,  R.  E. 

(Case  14.) 

A.  St.  P.,  Infantry,  wounded  Aug.  22,  1914,  at  L. ;  from 
Luneville,  he  was  admitted  Dec.  7,  1914. 

Condition. — The  fragment  has  penetrated  the  temporal 
region  a  finger's  breadth  from  the  outer  extremity  of  the 
eyebrow.  It  has  crossed  the  orbit  from  above  downwards 
and  from  behind  forwards  to  lodge  in  the  roof  of  the 
palate,  where  radiography  revealed  it,  and  where  it  still 


PRESERVATION  OF  THE  EYEBALL 


831 


remains  (Figs.  15  and  16).  The  wound  has  been  cicatrised 
for  a  long  time.  St.  P.  states  that  he  noticed  the  loss  of 
vision  in  the  right  eye  immediately  after  the  injury. 

The  right  eye  is  slightly  deviated  downwards  and  out- 
wards, due  to  paresis  of  the  inferior  oblique. 

The  anterior  segment  is  normal ;  the  pupil,  which  is 
equal  to  that  of  the  other  eye,  reacts  feebly  to  natural 
stimuli. 

R.  E.         V  =  1/200,  not  improved  by  glasses. 


Fig.  16. 

With  the  ophthalmoscope  detachment  of  the  retina  is 
seen  below;  near  the  posterior  pole,  in  the  region  of  the 
macula,  are  extensive  lesions  of  the  retina  and  choroid 
(probably  lacerations),  pearly  white  with  some  spots  of 
pigment  along  the  borders.  Lesions  due  to  concussion; 
eye  not  touched. 

There  is,  in  addition,  parsesthesia  in  the  region  supplied 
by  the  right  frontal  nerve. 

Left  eye  normal,  acuity  =  9/10. 

St.  P.  underwent  no  surgical  interference,  and  on  his 
discharge,  Feb.  6,  1914,  his  condition  remained  stationary. 


8.32 


FRACTURES  OF   THE  ORBIT 


Fifth  Group 

Fracture  by  bullet  of  the  floors  of  both  orbits  ;    double  retinal 
detachment ;   macular    lesion  on  the  left  by  concussion. 

(Case  15.) 

C,  Adjutant -chef,  Infantry,  wounded  Sep.  14,  1!)14,  at 
C.  From  the  divisional  ambulance  to  Fismes  and  thence 
to  Bordeaux,  where  he  arrived  Sep.  19. 

Condition. — A  rifie  bullet,  entering  the  right  malar 
region  near  the  lower  and  outer  angle  of  the  orbit  emerged 
at  a  point  almost  identical,  near  the  infero-external  angle 
of  the  left  orbit. 


Fig.  17. 

The  aperture  of  exit  is  very  extensive,  about  the  size  of 
a  crown-piece. 

The  ocular  affections  were  noticed  immediately  after 
the  injury. 

The  right  eye  is  outwardly  normal ;  there  exists  no  trace 
of  wound  or  contusion  of  the  appendages  or  of  the  anterior 
segment.  Pupil  dilated;  tension  manifestly  diminished 
(T.  -  1).  R.  E.  V  =  Quantitative.  The  visual  field^ 
persists  in  the  temporal  segment. 

Ophthalmoscopic  examination  discloses  a  detachment 
of  the  retina,  leaving  only  a  small  portion  of  the  nasal 
area  in  situ  ;  the  right  eye  has  been  injured  by  the  move- 
ment of  a  fragment  of  orbital  bone  (contact  lesions). 


PRESERVATION  OF  THE  EYEBALL         833 

The  tension  of  the  left  eye  is  equally  subnormal  (T.  —  1). 
Acuity  barely  1/20.  The  visual  field  shows  a  lacuna  in 
the  temporal  region,  corresponding  to  a  retinal  detachment 
limited  to  the  nasal  portion.  The  vitreous  is  the  seat  of 
numerous  floating  bodies,  due  to  haemorrhage. 

There  is  also  to  be  noted  anaesthesia  of  the  regions 
supplied  by  the  infra-orbital  nerves  (upper  lip,  supplied 
by  anterior  dental).  C.  also  complains  of  a  running  of 
tears  from  both  eyes,  indicating  that  the  nasal  canals  of 
the  lacrymal  passages  have  been  damaged  by  the  projectile. 

Usual  treatment  for  retinal  detachment. 

Feb.  16,  1915,  condition  as  follows  : — 
R.  E.         V  =  Quantitative. 
L.  E.        V  =  1/10  good. 

No  modification  of  the  visual  fields.  The  retinal  de- 
tachment on  the  right  is  extensive,  principally  below  and 
to  the  outer  side,  and  in  the  macular  region. 

On  the  left  side  the  disc  is  pale  and  surrounded  by 
pigment.  The  detachment  is  lessening,  but  in  its  place 
are  large  patches  of  choroido -retinitis  in  the  macular 
region:  right  eye  not  touched  (concussion  lesions). 

C.  was  discharged  Feb.  20,  1915. 

Fracture  of  left  orbit  by  bullet ;   detachment  of  retina,  L.  E. 

(Case  16.) 

E.  v.,  Infantry,  aged  31,  was  wounded  at  O.,  Oct.  12, 
1914.  From  Fontaine bleau  he  was  returned  to  his  depot 
in  the  beginning  of  November,  but,  complaining  of  his 
left  eye,  he  was  sent  to  the  ophthalmic  centre  of  the  18th 
Region  on  Dec.  7. 

Condition. — The  bullet  has  penetrated  the  lower  margin 
of  the  left  orbit  at  about  a  centimetre  from  the  inner 
canthus,  lacerating  the  lower  eyelid.  The  aperture  of  exit 
was  found  in  the  left  malar  bone,  a  little  in  front  of  the 
left  tempero-malar  articulation  (Fig.  18). 

V.  has  had  no  surgical  interference.  The  wound  is  quite 
cicatrised.  From  Oct.  12,  the  visual  acuity  of  the  left  eye 
has  gradually  diminished,  until  on  the  day  of  our  examina- 
tion it  was — 

L.  E.         V  =  1/50,  not  improved  by  glasses. 
The   ophthalmoscopic   examination   (Plate   VI,   Fig.    1) 
shows  a  retinal  detachment  in  the  lower  part,  reaching 


834 


FRACTURES  OF  THE  ORBIT 


nearly  up  to  the  macular  region.  There  are  some  floating 
opacities  in  the  vitreous.  It  is  probable  that  the  bullet 
in  its  course  has  brushed  against  the  lower  part  of  the 
globe,  without  leaving  any  trace  on  the  sclerotic;  there 
is  laceration  of  the  retina  and  choroid  extending  to  the 
macular  region  (contact  lesion).  (Plate  VI,  Fig.  1.) 
The  right  eye  is  normal : — 

R.  E..  with  -  1  D  sph.,  V  =  9/10. 

There  is,  in  addition,  anaesthesia  of  the  left  infra-orbital 
nerves  (left  half  of  the  upper  lip  and  left  incisors). 


Fig.  18. 


In  spite  of  the  orthodox  treatment  for  retinal  detach- 
ment, V.  was  discharged  on  Feb.  14,  not  improved. 

Bullet  wound  of  face  ;  fracture  of  left  inferior  orbital  margin  ; 
detachment  of  retina^  L.  E.    (Case  17.) 

A.  J.,  Infantry,  bullet  wound,  Sep.  9,  1914,  left  facial 
region.  Dazed  by  the  blow,  J.  noticed  immediate  and 
complete  loss  of  vision  of  the  left  eye,  accompanying  pro- 
fuse haemorrhage  in  the  inferior  conjunctival  cul-de-sac. 
Admitted  Sep.  14,  1914. 

Examination. — At  the  ambulance  of  Saintoing,  three 
injuries  were  noted  :  one  by  the  left  lower  lid,  one  in  the 
left  parotid  region,  the  third  on  the  left  shoulder  (Fig.  19). 

These  three  wounds  correspond  to  the  course  of  the 


PRESERVATION  OF  THE  EYEBALL 


835 


same  bullet,  which  entered  at  1  cm.  from  the  external 
angle  of  the  orbit,  perforating  the  lower  eyelid,  of  which 
it  divided  the  free  border,  fracturing  the  orbital  margin. 
At  this  point  the  ocular  conjunctiva  and  the  sclerotic 
have  been  slightly  wounded.  The  projectile  emerged  in 
the  parotid  region  and  wounded  the  shoulder  at  the  end 
of  its  course.  Radiography  confirms  the  presence  of  a 
loss  of  bony  substance  from  the  inferior  orbital  margin, 
the  crushing  of  the  malar  bone,  and  between  them  a  line 
of  fracture  in  the  zygomatic  arch  (Fig.  19). 

The  pupil  of  the  left  is  deformed ;   dilated  below,  in  the 
direction  of  the  scleral  wound.     The  tension  of  the  eye  is 


Fig.  19. 


leduced  (T,  —  1).  The  ophthalmoscope  discloses  a  very 
extensive  retinal  detachment  (contact  lesion). 

This  detachment  is  situated  on  the  side  of  the  scleral 
wound,  near  the  aperture  of  entrance  of  the  projectile. 

The  acuity  of  this  eye  is  1/100,  the  macular  region 
being  involved  in  the  retinal  detachment. 

The  right  eye  is  normal. 

Usual  treatment  for  retinal  detachment  (compression 
bandage,  atropine,  sub-conjunctival  injection  of  NaCl, 
rest  in  dorsal  decubitus). 

On  leaving  hospital,  Dec.  12,  1914,  no  apparent  im- 
provement had  been  produced ;  persistence  of  detachment. 


L.  E.        V  =  1/100. 


83G  FRACTURES  OF   THE  ORBIT 

Fracture  of  the  left  orbit  by  rifle  bullet ;   rupture  of  choroid. 

(Case  18.) 

A.  t).,  Infantry,  wounded  Sep.  15,  1914,  at  S. ;  under 
treatment  till  Nov.  23.  Admitted  Dec.  30  for  visual 
trouble  in  the  left  eye. 

Condition. — The  bullet  entered  under  the  left  eye,  below 
a  line  dropped  vertically  from  the  external  corneal  margin. 
There  is  no  trace  of  penetration  upon  the  skin  of  the 
eyelid,  but  a  small  scar  of  the  conjunctiva  with  slight 
symblepharon  indicates  the  orifice  of  entry.  The  aper- 
ture of  exit  is  found  under  the  left  ear  immediately  behind 


Fig.  20. 

the  ascending  ramus  of  the  mandible  and  a  finger's  breadth 
above  the  angle  of  the  same  bone  (Fig.  20). 

Radiography  shows  no  bony  lesions,  although  there  was 
a  fracture  of  the  orbital  floor. 

In  the  period  immediately  following  the  injury  he  had 
fairly  free  hsemorrhage  from  the  conjunctiva  as  well  as 
from  the  mouth. 

Sensation  is  preserved  in  the  region  supplied  by  the 
superior  and  inferior  maxillary  nerves;  the  malar  region 
and  the  left  cheek  present  evident  signs  of  inflammation ; 
the  region  is  a  little  tense,  red  and  painful. 

The  vision  of  the  left  eye  is  quantitative.  After  dilata- 
tion by  atropine,  no  lesions  of  the  anterior  segment  are 


PRESERVATION  OF  THE  EYEBALL         837 

seen.  The  bullet  has  grazed  the  sclerotic.  Transparent 
media  normal.  The  deep  membranes  are  the  seat  of 
very  serious  damage  :  optic  disc  softened  in  outline, 
peripapillary  and  macular  pigmentation  (concussion  lesion), 
and  pigmentation  also  in  the  lower  part  of  the  fundus. 
In  this  region  an  arciform  choroidal  laceration  is  also  seen 
(contact  lesion). 

The  right  eye  is  normal.     Visual  field  intact. 

R.  E.         V  =  l. 

Discharged  Feb.  1915,  with  the  ophthalmoscopic  appear- 
ance in  the  left  eye  unchanged, 

L.  E.         V  =  Quantitative. 

We  come  now  to  the  second  category  of  cases,  that  of 
fractures  of  the  orbit  with  preservation  of  the  eye  and  the 
presence  of  a  retained  foreign  body. 

Second  Category 

Fracture  of  right  orbit ;    Intra-orbital  foreign  body,  macular 
choroido-retinitis.    (Case  19.) 

C.  D.,  Infantry,  wounded  at  C,  Oct.  21,  1914,  by  shell 
fragment  in  the  right  temporal  region.  From  A,  via  Pau ; 
admitted  Dec.  12,  1914. 

The  aperture  of  entry  of  the  projectile  is  found  in  the 
right  temporal  region.  A  cicatrix  is  situated  a  finger's 
breadth  in  front  of  and  above  the  insertion  of  the  ear. 
Radiogram  shows  a  large  foreign  body  in  the  orbital 
cavity,  very  near  the  posterior  pole  of  the  eyeball.  The 
direction  followed  by  this  foreign  body  appears  to  have 
been  from  without  inwards  and  behind  forwards,  pene- 
trating the  orbit  through  the  great  wing  of  the  sphenoid 
(Fig.  21). 

Severe  orbital  inflammation  with  exophthalmos  followed 
the  injury,  but  there  is  no  trace  of  this  at  the  time  of 
examination. 

The  movements  of  the  extrinsic  muscles  are  preserved, 
with  the  exception  of  those  whicli  concern  the  paralysed 
levator  palpebrae  (ptosis  of  the  upper  eyelid). 

The  anterior  segment  and  the  transparent  media  of  the 
right  eye  are  in  good  condition,  but  the  deep  membranes 


838 


FRACTURES  OF  THE  ORBIT 


are  seriously  affected.  There  is  cicatricial  and  pigmentary 
degeneration  near  the  macula  and  in  the  outer  equatorial 
region.  Some  tracts  of  proliferating  retinitis  cover  in 
places  these  atrophic  patches  (organised  haemorrhage  of 
the  choroid  with  retinal  lacerations). 


R.  E. 
L.  E.,  with  +  1  Dsph.c 


V  -  0. 


-  2-5  D  cyl.,  axis.O^  V  =  9/10. 

Jan.  21,  1915,  Kronleins  operation,  following  the 
orthodox  procedure,  readily  permitted  the  extraction  of 
a  fragment  of  shell,  with  irregular  outline,  1  cm.  long  by 


Fig.  21. 

3  to  4  cm.  wide,  which  was  found  behind  the  eyeball, 
against  the  optic  nerve,  inside  the  cone  of  the  recti  muscles. 

Post-operative  conditions  normal ;  healing  per  primam. 

D.  left  hospital  Feb.  20,  1915,  for  discharge.  He  re- 
turned May  25,  1916,  complaining  of  much  pain  behind 
the  eye,  and  exhibiting  slight  blepharospasm.  A  new 
radiogram  showed  small  fragments  of  shell  disseminated 
in  the  fat  of  the  orbit.  The  patient  insisted  upon  their 
removal ;  a  second  operation,  with  turning  back  of  the 
external  orbital  wall,  was  performed  June  13 ;  powdered 
fragments  were  extracted,  no  foreign  body  of  any  size 
being  evident.  Healing  was  rapid;  relief  was  obtained 
from  the  symptoms,  which  were  largely  subjective.     When 


PRESERVATION  OF   THE  EYEBALL 


839 


he  went  out,  July  20,  there  v/as  no  change  in  the  condition 
of  the  eyeball. 

Fracture  of  the  superior-externial  margin  of  the  right  orbit ; 
intra-orbital  foreign  body  ;  exten^sive  choroido-retinitis, 
R.  E.    (Case  20.) 

R.,  Captain,  Infantry,  wouinded  Sep.  25,  1915,  by  shell 
in  the  right  orbital  region ;  admitted  three  days  later. 

Condition. — The  shell -fragment  has  penetrated  the  right 
upper  eyelid,  fracturing  the  upper  and  outer  margin  of 
the  orbit.  There  is  a  deep  niotch  in  the  bone,  into  which 
the  tip  of  the  index  finger  can  be  introduced  (Fig.  22). 


:Fig.  22. 

Almost  complete  ptosis  of  the  upper  eyelid  is  present; 
there  is  very  pronounced  exopllithalmos,  not  reducible, 
probably  due  to  an  intra-orbital  haematoma. 

The  pupil  is  dilated  to  the  majdmum  owing  to  paralysis 
of  the  sphincter  iridis.  There  is  no  effusion  into  the 
vitreous;  the  ophthalmoscope  reveals  a  disc  with  softened 
contour,  seen  as  though  through  a  mist.  In  the  macular 
region  is  a  large  haemorrhage,  which  is  continuous  above 
and  to  the  outer  side  wdth  a  choroidal  haemorrhage, 
resulting  from  rupture  of  this  membrane. 

R.  E.         V  =  0.  L.  E.        V  =  10/10. 

Radiography  demonstrates  the  situation  of  the  projectile 


840 


FRACTURES  OF   THE  ORBIT 


(Fig,  23) ;  a  voluminous  shell -fragment  has  pierced  the 
muscular  cone,  injuring  the  right  external  rectus  and 
coming  to  rest  behind  the  posterior  pole  of  the  eyeball 
which  it  has  probably  bruised  directly. 

Oct.  4,  1915,  Kronlein's  operation  :  after  a  curvilinear 
incision  of  the  integuments  external  to  the  orbit,  the  outer 
orbital  wall  was  raised  by  the  gouge.  A  probe  introduced 
in  the  track  followed  by  the  projectile  allowed  it  to  be 
felt  and  extracted. 

Recovery  from  the  operation  was  delayed  by  reason  of 
several  complications. 


Fio.  23. 


(1)  A  neuro-paralytic  keratitis  occurred,  which  was 
very  long  in  healing,  and  complete  recovery  was  only 
obtained  by  prolonged  occlusion  of  the  globe.  A  slight 
nebula  remained  when  the  patient  was  discharged. 

(2)  The  breach  in  the  orbital  bones  was  the  seat  of 
suppurative  osteitis,  resulting  in  a  sinus,  which  lasted  till 
June,  1916,  and  was  only  cured  by  a  further  operation,  in 
which  a  small  fragment  of  shell  and  a  splinter  of  bone 
were  extracted. 

On  leaving  hospital  Aug.  4,  1916,  the  exophthalmos  was 
not  entirely  reduced,  but  the  upper  eyelid  had  recovered 


PRESERVATION  OF   THE  EYEBALL 


841 


its  mobility.  There  was  complete  paralysis  of  the  right 
external  rectus.  Optic  disc  still  a  little  blurred;  large 
patches  of  post-haemorrhagic  atrophic  and  pigmentary 
choroido -retinitis  in  the  macular  region,  above,  to  the 
outer  side,  and  below. 


R.  E. 
L.  E. 


V  =  1/100. 

V  =  10/10. 


Fracture  of  left  orbit ;   intra-orbital,  fragment  of  bullet ;   optic 
atrophy   and  atrophic   and   pigmentary   choroido-retinitis. 

(Case  21.) 

B.,  Adjutant,   Curaissiers,  wounded  June  21,   1916,   at 


Fig.  24. 

M.,  by  a  bullet  in  right  orbital  region.  Was  first  at  Ch, 
Admitted  July  18,  1916. 

The  bullet  has  entered  by  the  lower  eyelid  at  1^  cm. 
from  the  free  border.  It  has  fractured  the  inferior  orbital 
margin,  where,  on  palpation,  a  deep  notch  is  felt.  Radio- 
graphy indicates  the  presence  of  the  foreign  body  in  the 
orbit,  situated  in  the  posterior  part,  near  the  apex  and 
close  to  the  roof  (Fig.  24). 

In  the  period  immediatelj^  following  the  injury  a  con- 
siderable amount  of  exophthalmos  was  j)i"oduced  b}^  the 
effusion  of  blood  and  inflammatory  exudates.  On  July  18 
this  exophthalmos  had  almost  disappeared.     Some  filaments 


842 


FRACTURES  OF  THE  ORBIT 


of  the  third  nerve  have  been  involved ;  the  pupil  is 
moderately  dilated  and  immobile ;  the  eye  is  divergent, 
owing  to  paralysis  of  the  nerve  to  the  right  internal  rectus. 

Externally  the  eyeball  is  normal ;  transparent  media 
intact. 

Disc  atrophic,  with  traces  of  old  perineuritis. 

The  posterior  pole,  in  the  macular  and  perimacular 
zones,  is  the  seat  of  numerous  patches  of  cicatricial  and 
pigmented  choroido-retinitis.  Vision  reduced  to  simple 
perception  of  light.     The  left  eye  is  normal. 


Fig    25. 

July  25,  Kronlein's  operation.  After  resection  of  the 
orbital  wall  and  section  of  the  external  rectus  muscle  the 
fibrous  track  resulting  from  the  passage  of  the  foreign 
body  was  reached.  It  was  found  at  the  apex  of  the.  or  bit, 
near  the  sphenoidal  fissure  (Fig.  25). 

The  copper  sheath  of  a  bullet,  greatly  distorted,  was 
extracted  without  difficulty.  Post-operative  progress 
normal.  There  remains  •  only  a  slight  paresis  of  the 
external  rectus  muscle,  in  a  fair  way  to  disappear.  The 
exophthalmos,  which  reappeared  after  the  surgical  inter- 
ference, passed  away  in  eight  or  ten  days. 

Sep.  7,  1916,  B.  left  for  three  months'  sick  leave. 


PRESERVATION  OF  THE  EYEBALL 


843 


Fracture  of  left  orbit  by  shrapnell  ball ;  optic  atrophy. 

(Case  22.) 

L.  T.,  Infantry,  wounded  Sep.  16,  at  V.  Was  at  Fimes 
two  days  later,  and  then  at  Casteljaloux.  Sent  on  as  con- 
valescent, without  any  surgical  interference,  he  noticed 
a  rapid  diminution  of  vision  in  the  left  eye,  and  was 
admitted  Nov.  26,  1914. 

Condition. — At  the  level  of  the  left  frontal  sinus  there 
is  a  cicatrix  about  1|  cm.  above  the  internal  superior 
angle  of  the  orbit.  The  base  of  the  frontal  sinus  has 
probably  been  crushed  in. 


Fig.  26. 

The  left  eye  is  slightly  divergent,  owing  to  paresis  of 
the  internal  rectus,  very  faintly  marked.  The  pupil 
reacts  very  feebly  to  its  natural  stimuli.  The  ocular 
media  are  normal,  but  the  optic  disc  is  in  a  fair  way 
towards  white  atrophy,  primary,  not  post-neuritic. 

L.  E.        V  =  1/30; 

The  visual  field  is  concentrically  contracted;  blue  and 
green  are  not  perceived. 

Radiography  shows  the  presence  of  a  shrapnel  ball  at 
the  apex  of  the  orbit. 

R.  E.  normal.        V  =-  10/10. 


su 


FRACTURES  OF  THE  ORBIT 


Dec.  3,  1914,  the  projectile  was  extracted  by  a  curvi- 
linear incision,  situated  above  and  to  the  inner  side  of  the 
lacrymal  sac.  It  was  found  in  a  bony  mass  in  the  wall 
at  the  apex ;  extraction  difficult  because  of  tJie  tenacious 
adherence  of  the  newly  formed  tissue. 

Post-operative  progress  normal. 

On  discharge,  Jan.  17,  1915,  recovery  was  complete,  but 
the  optic  atrophy  had  progressed.     The  pallor  of  the  disc 
has  increased  and  the  visual  acuity  is  scarcely  1/200. 
In  April,  1916,  L.  E.         V  =  0. 


Fig.  27. 

Fracture  of  the  right  orbit ;   intra-orbital  foreign  boay  ; 
extraction  by  KrOnlein's  method.    (Case  23.) 

H.  L.,  Zouaves,  wound  by  revolver  shot,  June  9,  1914. 
The  shot  had  penetrated  the  superior  external  region  of 
the  right  orbit ;  the  size  of  the  projectile  was  8  mm.  Im- 
mediate loss  of  consciousness,  lasting  about  half  an  hour ; 
the  sequelse  of  the  injury  were  of  the  simplest  and  only 
diplopia  remained,  due  to  paralysis  of  the  external  rectus. 

L.,  by  acquiring  the  habit  of  holding  his  head  in  an 
apjpropriate  position,  succeeded  in  suppressing  the  diplopia, 
and  went  on  active  service  for  eight  months.  In  Nov. 
1915,  suffering  from  violent  pains  in  the  head,  he  was 
admitted  June  1,  1916  (Fig.  27). 

Condition  — In  the  supero-external  and  lateral  region  of 


PRESERVATION   OF   THE  EYEBALL         845 

the  right  orbit  is  a  cicatrix,  the  a})erture  of  entry  ot  the 
projectile.  This  scar  is  1|  cm.  behind  the  outer  limit  of 
the  eyebrow.  The  bullet,  following  a  horizontal  course 
from  mthout  inwards,  has  perforated  the  external  orbital 
wall  behind  the  eyeball  and  come  to  rest  in  the  muscular 
cone  at  a  distance  of  1|  cm.  from  the  posterior  pole  of  the 
eye,  in  contact  with  the  optic  nerve,  which  has  not  been 
injured  (Fig.  28). 

The   right    eyeball   is    normal.     The    ocular    media    are 


Fig.  28. 


quite  transparent ;   the  disc  presents  no  sign  of  atrophy. 
Visual  acuity  =  10/10. 

The  external  rectus  muscle  is  slightly  paralysed,  having 
probably  been  perforated  by  the  bullet. 

June  10,  1916,  Kronlein's  operation  with  large  curvilinear 
incision  of  the  integuments  over  the  external  orbital  wall 
The  projectile  was  found  in  the  middle  of  the  four  recti 
muscles,  ensheathed  in  very  dense  fibrous  tissue.  Extrac- 
tion was  easy.  Post-operative  conditions  normal.  There 
remains, only  marked  paralysis  of  the  external  rectus  muscle, 
accentuating  the  diplopia  of  which  the  patient  previously 
complained. 


846  FRACTURES  OF  THE  ORBIT 

Sep.  14,  1916,  tenotomy  of  the  internal  rectus  and 
advancement  of  the  external  rectus  were  performed. 
These  operations,  combined  with  fusion  exercises  with  the 
diploscope,  brought  about  a  great  improvement  in  the 
diplopia,  which  still  exists  to  a  slight  extent  in  the  region 
of  action  of  the  right  external  rectus  muscle. 

R.  E.         V  =  10/10. 

Shell  wound  with  intra-orbital  foreign  body  :    fracture  of  the 
external  wall  of  the  left  orbit ;  multiple  retinal  detachments. 

(Case  24.) 

J.  R.,  Private,  wounded  at  V.,  March  13,  1916;  reached 
Bordeaux  March  18. 

Condition. — A  Y-shaped  cicatrix  is  seen  in  the  left 
orbito-frontal  region,  the  fork  directed  towards  the  ear, 
extending  from  the  centre  of  the  left  eyebrow  to  the 
middle  of  the  temporal  fossa  (Fig.  29). 

The  injury  at  its  two  extremities  involved  the  soft  parts 
only.  In  its  median  portion  the  scar  is  adherent  to  the 
superciliary  ridge,  in  a  bony  depression  corresponding  to 
the  external  margin  of  the  orbit,  which  has  been  bevelled 
off  by  the  projectile. 

Radiography  discloses  a  loss  of  substance  in  the  external 
and  superior  orbital  region,  a  zone  from  which  several 
splinters  have  been  extracted,  as  well  as  a  fragment  of 
shell,  which  was  intra -orbital  and  situated  above  the 
eyeball. 

The  violent  contusion  had  caused  profuse  haemorrhage 
into  the  vitreous  of  the  left  eye,  which  during  the  first 
months  of  his  stay  in  hospital  did  not  allow  of  examination 
of  the  fundus.     Tension  reduced  (T  —  2). 

L.  E.  V=:0. 

May  25,  1916,  the  ophthalmoscope  showed  almost  com- 
plete disappearance  of  the  haemorrhage  into  the  vitreous, 
only  some  floating  opacities  remaining.  There  are  large 
retinal  detachments,  one  peripheral  in  the  nasal  equatorial 
region,  the  other  occupying  the  macular  region  and  the 
temporal  region  (contact  lesion).  The  disc  is  slightly  pale 
(Fig.  30).     Visual  acuity  1/200. 

This  condition  does  not  appear  to  be  final,  for  traumatic 


PRESERVATION  OF  THE  EYEBALL         847 


Fig.  29. 


848 


FRACTURES  OF  THE  ORBIT 


retinal  detachments  improve  and  disaj^pear  with  the  lapse 
af  time. 

R.  E.  normal.         V  =  10/10. 

Fracture  of  left  orbit ;  intra-orbital  foreign  body  ;  macular 
choroiditis.  (Case  25.) 
J.  H.,  Officer,  Colonial  Artillery;  wounded  Sep.  1,  1914, 
at  A.,  by  shell  fragments,  in  left  orbital  region.  At  the 
Orleans  hospital  till  Sep.  20,  when  he  was  returned  to 
his  depot.  Complaining  that  he  could  riot  see,  he  was 
admitted  Nov.  15,  1914. 


Fig.  31. 

Condition. — H.  presents  a  wound  near  the  external 
canthus  of  the  left  eye.  The  projectile  has  penetrated 
the  orbit,  fracturing  the  infero-external  margin,  where 
there  is  a  small  cicatrix  with  symblepharon  at  the  aj)erture 
of  entry.  Immediately  following  the  injury  considerable 
exophthalmos  was  produced  by  intra-orbital  effusion  of 
blood,  of  which  no  trace  remains  (Fig.  31). 

There  is  no  lesion  of  the  appendages ;  the  movements 
of  the  globe  are  well  preserved ;  no  affection  of  the  anterior 
segment  or  the  transparent  media.  With  the  ophthal- 
moscope, however,  one  notes  a  well-marked  macular  lesion, 
with  a  zone  of  atrophy,  and  below  it  a  zone  of  pigmenta- 
tion. Further,  in  the  neighbourhood  of  the  aperture  of 
entry  there  is  to  be  seen  an  extensive  patch  of  atrophic 


PRESERVATION  OF  THE  EYEBALL         849 

and  pigmented  choroido -retinitis,  indicating  that  the  shell 

fragment,  in  penetrating  the  orbit,  has  grazed  the  eyeball. 

Perirxxotiic  examination  reveals  the  existence  of  a  central 

scotoma  extending  into  the  upper  part  of  the  visual  field, 

L.  E.,  with  -f  050  D  sph.,     V  =  Quantitative. 
R.  E.  normal.         V  =  10/10. 

Radiography  shows  two  shell  fragments.  The  more 
bulky  seems  to  be  in  the  antrum.  The  smaller  is  in  the 
left  orbit,  behind  the  eyeball. 

Nov.  22,  1914,  the  orbit  was  opened  from  the  outer  side, 
after  a  curvilinear  incision,  but  without  excision  of  bone. 
The  eye,  after  section  of  the  external  rectus  muscle,  was 
hooked  inwards ;  the  portion  of  shell,  encapsuled  in  fibrous 
scar-tissue,  was  readily  removed. 

Post-operative  progress  without  inflammatory  com- 
plications, but)  shortly  after,  blepharospasm  appeared, 
probably  caused  by  irritation  of  the  infra-orbital  nerve, 
consecutive  to  the  traumatism  and  the  temporary  sojourn 
in  the  region  of  the  nerve  of  the  foreign  bodies  which  were 
now  removed. 

The  nerve  was  resected  in  the  orbit  Dec.  15,  1914. 
Blepharospasm  quickly  disappeared,  and  H.  was  discharged 
Jan.  4,  1915,  with  the  vision  of  the  left  eye  unaltered. 


§  II. — Pathology  of  the  Visual  Disorders 
First  Group 

The  visual  affections  of  the  first  group  are  explained 
by  damage  to  sensory  nerves  (lacrymal,  frontal),  the 
various  motor  nerves,  and  by  lesion  of  the  optic  nerve, 
the  consequences  of  the  propagation  to  these  organs  of. 
fractures  of  the  orbital  vault,  radiated  or  by  contre- 
coup. 

Atrophy  of  the  optic  nerve,  following  injury  of  the 
nerve,  upon  which  many  authors,  and  particularly 
Chauvel  and  Nimier  have  insisted,  explains  itself : 
it  is  not  so  easy  to  account  for  the  trophic  and  sensory 
affections  presented  by  the  patients,  particularly  by 
the  cases  of  enophthalmos.     (Case  39  et  seq.) 


850  FRACTURES  OF  THE  ORBIT 

It  is  probable  that  in  cases  where  enophthalmos 
has  occurred  the  sympathetic  nerve  has  been  injured 
at  its  entry  into  the  orbit  or  within  the  orbit  itself. 
Section  of  the  cervical  sympathetic,  or  rather,  the 
suppression  of  the  action  of  this  nerve,  will  explain 
enophthalmos  satisfactorily.  Laceration  of  the  nerve 
filaments  produces  this  result,  but  irritation,  continued 
excitation  of  the  same  nerve  filaments,  also  induces  it, 
for  the  excitability  of  a  nerve  diminishes  in  proportion 
as  the  excitation  is  prolonged  and  increased  in  intensity, 
so  that  a  very  prolonged  irritation  amounts  to  the  same 
as  section — that  is  to  say,  to  enophthalmos. 

This  enophthalmos  is  therefore  equally  well  explained 
by  complete  laceration,  section  of  the  trophic  nerve 
filaments,  and  by  irritation  of  these  nerve  filaments 
prolonged  over  a  long  period ;  continued  excitation, 
prolonged  irritation,  as  well  as  laceration  of  the  nerves, 
are  themselves  explained  by  radiation  of  the  cranial 
fracture  into  the  sphenoidal  fissure. 

Second  Group 

The  macular  lesions  we  fihd  in  eyes  which  are 
to  all  appearance  absolutely  intact,  disturbed  at 
a  distance  by  injury  implicating  the  bony  mass  of 
the  face,  far  from  the  orbit,  result  from  the  propa- 
gation of  the  vibratory  concussion  to  the  orbital 
contents  by  way  of  the  fossa  and  the  ptery  go -maxillary 
fissure. 

The  eye  is  raised,  shaken  as  a  submerged  boat  would 
be  when  struck  by  a  deep  wave,  attacking  it  from 
beneath.  It  is  probable  that  this  concussion  of  the 
whole  mass  of  orbital  fat,  which  is  semi-fluid  at  the 
temperature  of  the  body,  is  the  cause  of  the  ruptures 
produced  in  the  deep  membranes. 

How  is  it  that  these  injuries  are  often  exclusively 
macular,  and  that  when  ruptures  occur  elsewhere  the 
chief  lesions  are  at  the  posterior  pole  ?  It  is  possible  to 
explain  such  localisation  :  in  the  first  place,  by  this  fact, 
that  the  macular  region  is  the  most  fragile,  the  most 


PRESERVATION  OF   THE  EYEBALL         851 

sensitive  to  injury  and  to  traumatism ;  in  the  second 
place,  because  the  eye,  tossed  forward  by  the  wave  of 
oscillation  which  agitates  the  depths  of  the  orbit  be- 
hind the  globe,  is  held  back  by  the  optic  nerve  firmly 
attached  to  the  apex  of  the  orbit. 

This  traction  is  exerted  on  the  whole  of  the  posterior 
pole,  and  hence  localises  ruptures  and  haemorrhages 
to  this  region.  Sometimes  patients  whose  faces 
have  been  severely  contused  have  lost  central  vision 
without  the  macula  presenting  any  visible  lesions. 
One  must  beware  of  concluding  that  this  is  due  to 
malingering ;  central  scotomata  are  quite  well  explained 
by  the  existence  of  disorders  which  are  invisible  by 
ophthalmoscopic  examination. 

Third  Group 

The  affections  of  the  third  group,  which  are  conse- 
cutive to  the  depression,  the  impaction,  more  or  less 
marked,  of  one  of  the  walls  of  the  orbit,  are  amenable 
to  the  same  explanation,  and  one  can  understand  that 
they  may  be  even  more  marked  than  when  the  projec- 
tile has  traversed  the  bony  mass  of  the  face  without 
altering  the  conformation  of  the  orbital  cavity.  Here 
it  is  the  pillars  and  the  sides,  not  the  basement  of 
the  vault,  which  are  assailed ;  it  is  easy  to  understand 
that  the  organs  which  are  contained  in  the  orbital 
cavity  are  more  seriously  affected  by  the  injuries  which 
crack  or  perforate  the  actual  walls  and  pillars  of  the 
edifice. 

In  this  third  group  there  are  macular  lesions  which 
are  explicable  by  the  mechanism  we  have  explained 
above  ;  but  there  are  also  vast  choroidal  lesions  which 
are  ruptures  resulting  from  the  violence  transmitted 
by  the  fluid  material.  These  latter  lesions  vary  in  de- 
gree according  to  the  amount  of  depression  of  the  orbital 
walls  and  the  severity  of  the  shock. 

They  are  remarkable  from  the  point  of  view  of  locali- 
sation by  the  fact  that  they  are  always  situated  on  the 
side  of  the  orbital  fracture ;  the  wave  which  jars  the  soft 


852  FRACTURES  OF   THE  ORBIT 

parts  starts  from  the  site  of  the  fracture  and  strikes 
the  eye  in  front  of  it  with  a  sharp  blow,  rupturing  its 
membranes.  It  is  agreed  that  the  tearing  affects  first 
and  foremost  the  choroid,  which  bleeds ;  the  blood 
lifts  up  the  retina  and  detaches  it.  When  the  latter 
membrane  is  itself  torn  a  choroido -retinitis  proliferans 
is  produced,  a  condition  of  which  we  have  seen  a  large 
number  of  typical  examples. 

Summing  up,  in  the  third  group  we  find— 
(1)  a  definite  macular  lesion;    (2)  a  choroidal  rup- 
ture, most  frequent ;  sometimes  choroidal  and  retinal 
ruptures,  on  the  side  of  the  fractured  orbital  wall. 

Fourth  Group 

When  the  projectile  has  traversed  the  orbit  without 
touching  the  eye  it  is  obvious  that  very  different  results 
may  be  produced  according  to  the  organs — muscles, 
motor  and  sensory  nerves,  etc. — which  are  injured. 
The  same  bullet  may  traverse  both  orbits  and  sever 
both  optic  nerves  behind  the  globe.  We  have  noted 
several  cases  of  this  nature.  When  the  optic  nerve 
has  been  divided,  or  when  it  has  been  severely  bruised, 
much  damage  is  done  at  the  posterior  pole  owing  to  the 
traction  exerted  on  the  eye  by  the  nerve.  The  force, 
before  dividing  and  bruising  the  nerve,  thrusts  it 
violently  forwards  in  the  direction  in  which  the  pro- 
jectile is  travelling,  and  tends  to  tear  it  from  its  inser- 
tion in  the  eyeball. 

Cases  9  and  10  (Plate  III,  Fig.  1 ;  Fig,  35)  are 
examples  of  this  type.  The  pathogenesis  of  such 
lesions  presents  no  obscurity. 

Lacerations  of  motor  and  sensory  nerves  and  of 
muscles  can  be  readily  explained ;  there  is  no  need  to 
stop  to  consider  them. 

Fifth  Gropip 

The  fifth  group  of  ocular  disorders  comprises  cases  of 
direct  contusion  of  the  globe,  without  rupture  of  its 


PRESERVATTON  OF   THE  EYEBALL         853 

walls,  by  a  projectile  which  passes  it  tangentially  and 
to  some  extent  grazes  it. 

Under  these  conditions  there  are  always  lesions  ex- 
actly where  the  missile  has  touched  the  eye.  They  are 
contact  lesions,  and  are  of  the  nature  of  ruptures  of  the 
choroid  and  retina. 

Often  the  two  membranes  are  simultaneously  torn, 
owing  to  the  violence  of  the  shock ;  the  destiiiction  is 
very  great,  has  its  point  of  election  at  the  point  touched, 
and  is  readily  propagated  to  the  macular  region.  The 
macula  is  in  consequence  often  implicated  under 
these  circumstances,  but  not  as  an  isolated  and  separate 
lesion.  In  such  cases  the  eyeball  may  be  disorganised 
without  being  ruptured.  Obviously,  if  the  missile 
passes  too  near  the  eye  it  destroys  it  by  making  it 
burst,  but  we  are  not  speaking  of  ruptures  of  the  globe. 
Our  fifth  group  comprises  the  cases  in  which  the  eye  is 
directly  contused  by  a  projectile,  which  grazes  it  in 
passing,  without  rupturing  it.  It  is  evident  that  under 
such  circumstances  we  must  expect  to  find  the  greatest 
destruction  in  the  deep  membranes.  From  the  site 
of  contusion  lacerations  spread  out  into  all  directions, 
especially  involving  the  posterior  pole,  which  is  always 
very  sensitive  to  injury. 

The  visual  troubles  which  are  produced  in  the  cases 
in  which  fracture  of  the  orbit  is  complicated  by  the 
presence  of  a  foreign  body  are  explained  in  the  same 
manner  as  in  the  cases  belonging  to  the  two  last  groups. 
It  is  needless  to  consider  them  further. 


§  III. — Description  of  the  Visual  Defects 

Such  are,  from  the  point  of  view  of  their  mechanism, 
the  affections  of  the  visual  apparatus  which  are  caused 
by  fractures  of  the  orbit  in  which  the  eye  is  preserved. 

We  must  now  discuss  each  in  turn,  studying  them  in 
the  following  order  : — 

(A)  Nerve  lesions:  1st,  motor:  2nd,  sensory:  3rd. 
sympathetic;  4th,  those  of  special  sense. 


854  FRACTURES  OF  THE  ORBIT 

(B)  Lesions  of  vessels  :  Ophthalmic  artery  and  vein ; 
traumatic  haemorrhage  into  the  orbit. 

(C)  Lesions  of  the  intrinsic  and  extrinsic  muscles. 

(D)  Affections  of  the  eyeball:  1st,  of  the  transpa- 
rent media ;  cataracts,  luxation  of  the  lens  :  2nd,  of 
the  membranes,  (a)  uveal  tract ;  [b)  retina,  traumatic 
detachment. 

(E)  Traumatic  enophthalmos . 

We  shall  study  these  various  disorders  mider  their 
separate  headings. 

A. — Lesions  of  Nerves  :  Motor,  Sensory,  Sympa- 
thetic, AND  OF  Special  Sense 

In  order  thoroughly  to  grasp  the  nervous  affections 
which  are  brought  about  in  the  visual  apparatus  by 
injuries  to  the  orbit  it  is  necessary  to  bear  in  mind  the 
sphenoidal  fissure,  which  we  represent  here  according 
to  the  recognised  authorities. 

No  anatomical  description  will  be  given — the  reading 
of  the  legend  which  accompanies  the  illustration  will 
suffice  to  enable  our  readers  to  follow  the  demonstration 
of  the  cases  we  have  observed. 

It  is  easy  to  understand  which  nerve  trunks  will  be 
most  likely  to  be  implicated  by  a  fracture  radiating 
into  the  roof  of  the  orbit,  or  by  a  direct  blow  upon  the 
wall  of  the  orbit. 

(1)  Motor  Nerves 

The  nerve  most  often  injured  is  the  oculo-motor 
(Ilird) ;  this  paralysis  is  due  in  the  majority  of  cases  to 
a  fracture  of  the  superior  wall  of  the  sphenoidal  fissure, 
particularly  of  the  anterior  clinoid  process,  on  account 
of  the  relations  of  the  nerve  with  this  process.  Fre- 
quently there  co-exists,  for  the  same  reason,  a  traumatic 
amaurosis.  The  same  reasoning  does  not  apply  to  the 
sixth  nerve,  which  is  the  farthest  removed  from  the 
superior  wall  of  the  sphenoidal  fissure  ;  paralysis  of  this 
nerve  is  usually  due  to  fracture  of  the  base. 


PRESERVATION^  OF  THE  EYEBALL 


855 


Paralysis  of  the  fourth  nerve  may  be  equally  due  to  a 
fracture  of  the  roof  of  the  sphenoidal  fissure,  for  this 


6    8 


P     1      L^.fj 


Fig.  32. — The  sphenoidal  fissure  and  the  organs  which  pass 
through  it  (after  Testut  and  Jacob). 

The  sphenoidal  fissure  is  viewed  from  the  interior  of  the  cranium. 
The  periosteum  and  the  dura  mater  which  close  it  have  been  in- 
cised and  the  flaps  hooked  back.  The  cavernous  sinus  has  been 
opened. 

1.  Inferior  border  of  the  sphenoidal  fissure.  2.  Superior  border. 
3.  Anterior  clinoid  process  divided  at  its  base.  4.  Posterior 
clinoid  process.  5,  5'.  Ring  of  Zinn.  6.  External  rectus  muscle. 
7.  Lacrymal  nerve.  8.  Frontal  nerve.  9.  Pathetic  (fourth  or 
trochlear).  10.  Motor  oculi  (third).  11.  Common  tnmk  of  lac- 
rymal and  frontal  nerves.  12.  Nasal  nerve.  13.  External  motor 
oculi  (sixth).  14.  Inferior  ophthalmic  vein.  15.  Inferior  vein. 
16.  Cavernous  sinus.  17.  Internal  carotid.  18.  Optic  nerve.  19. 
Superior  maxillary  nerve.  20.  Ophthalmic  of  Willis  (first  division 
of  the  fifth).     21.  Orbital  fatty  tissue. 

nerve  is  quite  close  to  it ;   paralysis  of  the  ophthalmic 
branch  of  the  trigeminal  may  be  due  to  the  same  cause. 


856  FRACTURES  OF  THE  ORBIT 

When  the  whole  of  the  trigeminal  is  implicated  the 
explanation  of  its  paralysis  must  be  sought  in  a  fracture 
of  the  apex  of  the  petrous  portion  of  the  temporal  bone. 
These  are  the  conclusions  to  which  Ferron  arrived 
in  an  excellent  Thesis  on  this  subject  (Lyons,  1901). 
This  author,  moreover,  very  justly  remarks  that  paraly- 
sis of  the  nerves  of  the  orbit,  when  they  have  not  an 
orbital  cause,  are  symptoms  of  fracture  of  the  base  of 
the  cranium. 

This  is  not  the  place  to  demonstrate  the  mechanism 
by  which  fractures  of  the  cranium  are  propagated  to 
the  orbital  vault.  We  refer  readers  to  the  authorities 
on  this  question,  especially  to  the  article  "  Orbite  " 
by  RoLLET,  in  fEncyclopedie  d'Ophtalmologie  *'  (Vol. 
VIII)  ;  in  order  to  comprehend  the  cause  of  the  nerve 
lesions  which  we  have  observed  in  orbital  fractures  it 
will  be  sufficient  for  us  to  recall  the  anatomical  data 
given  in  Fig.  32. 

We  have  seen  four  cases  of  paralysis  of  the  third 
nerve,  two  of  paralysis  of  the  sixth,  one  of  paralysis 
of  the  fourth.  We  have  noted  another  disturbance  in 
the  action  of  the  superior  oblique  due  to  dislocation 
of  the  pulley  of  this  muscle.  When  the  sixth  nerve 
is  affected  the  cause  is  most  frequently  orbital ;  we 
have  twice  found  paralysis  of  abduction  after  fractures 
by  direct  shock  upon  the  temporal  wall  of  the  orbit. 

(2)  Sensory  Nerve 

The  trigeminal,  in  fractures  of  the  orbit,  may  be 
damaged  not  only  in  its  first  branch,  the  ophthalmic 
of  Willis,  but  it  is  not  uncommon  to  find  that  fracture 
of  the  floor  of  the  orbit  implicates  the  superior  maxillary 
nerve,  which  is  rarely  divided,  more  often  compressed. 
Anaesthesia  in  the  corresponding  region  follows,  and 
often  too,  signs  of  irritation,  of  which  we  have  notes 
of  two  cases  presenting  an  obstinate  blepharospasm 
which  yielded  only  to  surgical  interference.  In  the 
first  case  a  piece  of  shell,  penetrating  1  cm.  below 
the   inferior   orbital    margin,    probably    damaged   the 


PRESERVATION  OF  THE  EYEBALL         857 

infra-orbital  nerve  before  coming  to  rest  in  the  orbit, 
from  which  we  extracted  it.  The  second  patient  was 
struck  by  a  projectile  which  smashed  in  the  orbital 
floor  without  penetrating  the  tissues.  The  blepharo- 
spasm was  confined  to  the  lower  eyelid.  We  performed 
on  both  subjects  resection  of  the  nerve  trunk  in  the 
orbit,  according  to  the  orthodox  procedure,  and  the 
contractions  of  the  lids  rapidly  disappeared  in  the  period 
following  the  surgical  interference. 

(3)  Sympathetic  Nerve 

Branches  of  the  ophthalmic  nerve  of  Willis  may 
be  injured  and  with  them  the  vaso -motor  filaments 
they  contain,  and  it  is  not  rare,  in  addition  to  corneal 
anaesthesia,  to  see  neuro -paralytic  troubles,  the  more 
readily  explicable  because  the  sympathetic  filaments 
may  have  been  equally  affected  by  the  traumatism. 

It  is  not  impossible,  however,  for  the  injury  to  impli- 
cate all  the  nerves  at  the  same  time,  with  the  exception 
of  the  sympathetic,  and  we  have  met  with  an  interesting 
case  which  merits  consideration  from  this  point  of 
view. 

Fracture  of  left  orbit ;    total  ophthalmoplegia  ;  •  optic  atrophy 
L.  E.     (Case  26.) 

J.  A.,  Infantry,  wounded  Sep.  30,  1914,  near  R.  At 
Chalons  till  Dec.  4;  admitted  Dec.  8. 

Condition. — Struck  by  shrapnel  ball  in  the  left  temporo- 
parietal region,  two  fingers'  breadth  above  the  insertion 
of  the  ear,  three  fingers'  breadth  behind  the  extremity  of 
the  eyebrow. 

Radiography  in  profile  shows  the  projectile  situated 
immediately  in  front  of  the  sella  turcica;  and  the  radio- 
gram, taken  from  in  front,  indicates  its  presence  against 
the  superior  internal  wall  of  the  left  orbit.  It  has  there- 
fore in  its  course  involved  the  apex  of  the  orbit  slightly 
in  front  of  the  sphenoidal  fissure,  which  it  has  doubtless 
smashed  in  (Figs.  33  and  34). 

The  upper  eyelid  is  in  a  condition  of  complete  ptosis. 
The  eyeball  is  quite  immobile ;    all  the  extrinsic  muscles 


858 


FRACTURES  OF  THE  ORBIT 


are  paralysed.  There  is  no  exophthalmos;  but  the  eye 
is  slightly  deviated  to  the  outer  side,  in  the  orbital  axis. 

The  anterior  segment  is  normal ;  the  pupil,  very  dilated, 
reacts  neither  directly  nor  consensually  (Fig.  34). 

The  anaesthesia  extends  over  the  whole  of  the  region 
supplied  by  the  trigeminal,  total  for  the  ophthalmic  branch 
of  Willis,  partial  so  far  as  concerns  the  dental  and  infra- 
orbital branches. 


Fig.  33. 


Ophthalmoscopic  examination  reveals  white  atrophy  of 
the  optic  nerve ;  the  veins  are  normal,  but  the  arteries  are 
very  slender. 

L.  E.        V  =  0. 


No  lesion  of  the  transparent 
The  visual  field  is  normal. 


The  right  eye  is  intact 
media  or  deep  membranes 

R.  E.,  with  +  1  t)  sph.,  V  =  1. 

Taking  into  consideration  the  very  deep  situation  of  the 
projectile,   the  dangers  inseparable  from  its  extraction, 


PRESERVATION  OF  THE  EYEBALL 


859 


and  the  perfect  tolerance  for  it  displayed  by  the  brain, 
surgical  interference  was  postponed,  and  the  patient  left 
hospital  March  9,  1915. 

In  this  curious  case,  all  the  nerves  of  the  eye  without 
exception  were  implicated,  and  still  the  eye  survived. 
It  only  presented  neuro -paralytic  phenomena  ;  the  fact 
must  be  explained  by  preservation  of  the  ophthalmic 


Fig.  34. 


ganglion,  that  tiny  brain  of  the  eye,  which  continued 
to  control  its  nutrition. 

Of  all  the  lesions  presented  by  the  nervous  apparatus 
of  the  eye  those  of  the  optic  nerve  must  be  dealt 
with  at  greatest  length. 

(4)  Lesions  of  the  Optic  Nerve 

It  is  ponvenient  to  divide  the  traumatic  le»iOns  of 
the  optic  nerve  resulting  from  injuries  of  war  into 
three  classes,  according  to  localisation :  (a)  the  intra- 
ocular portion ;     (6)   the  retrobulbar   portion,  which 


860 


FRACTURES  OF  THE  ORBIT 


contains  the  central  artery  and  veins ;  (c)  the  non- 
vascular portion,  which  extends  from  the  optic  foramen 
to  the  entrance  of  the  central  artery  and  vein. 

{a)  Intra-ocular  portion ;  traumatic  lesions  of  the 
papilla. — These  are  the  injuries  which  we  find  when 
the  papilla  has  been  torn  out  by  a  sudden  stretching 
of  the  optic  nerve.     A  blunt  instrument  or  a  metallic 


Fig.  35. — Avulsion  of  the  optic  nerve. 

fragment  sharply  pushes  aside  the  nerve,  tears  it  out, 
so  to  speak,  and  detaches  it  from  its  insertion  into  the 
globe.  We  have  observed  several  examples  of  this 
condition  in  which  the  ophthalmoscopic  appearance  was 
similar  to  that  which  Gonin  gives  in  the  Encyclopedie 
frangaise  (Vol.  VII,  p.  534). 

Free  haemorrhage  at  once  follows  the  avulsion,  and 
when  the  blood  has  absorbed  we  see  the  remnants  of 
torn  vessels  and  sometimes  a  deep  excavation  due  to 


PRESERVATION  OF   THE  EYEBALL         8G1 

rupture  of  the  sclerotic.  .  In  a  case  of  Pagenstecher's 
the  nerve  had  been  absolutely  torn  out  from  the 
scleral  ring,  and  the  retina  had  been  dragged  into  the 
opening. 

In  this  manner  a  traumatic  excavation  of  the 
disc  is  produced,  a  sort  of  coloboma  or  surgical 
conus,  much  more  pronounced  than  the  glaucomat- 
ous excavation.  Gonin  quotes  a  case  of  Birch- 
Hirschfeld's  in  which  the  difference  of  level  was 
2  mm.  This  excavation  may  become  filled  with  pro- 
liferating connective  tissue,  in  the  same  manner  as  in 
retinitis  proliferans. 

Gunshot  wounds  of  the  temple  in  attempts  at  suicide 
have  afforded  opportunities  for  the  study  of  this  type 
of  lesion,  of  which  w^e  have  notes  of  several  cases 
amongst  our  wounded  (Fig.  35,  and  Plate  III, 
Figs.  1  and  2).  It  will  be  understood  how,  besides 
total  or  sub-total  avulsion  of  the  papilla,  partial 
luxations,  more  or  less  pronounced,  may  occur,  and 
between  the  most  complete  total  detachment  and  the 
most  moderate  partial  luxation  it  is  easy  to  conceive 
all  the  varieties  which  have  been  demonstrated  at  our 
centres  of  military  ophthalmology. 

(6)  Lesions  of  the  nerve  in  the  retrobulbar  portion 
which  contains  the  central  artery  and  vein. — A  projec- 
tile entering  the  orbit  immediately  behind  the  eye 
may  divide  the  nerve  more  or  less  completely, 
tearing  it,  and  with  it  the  vessels  which  it  contains. 
In  these  cases  an  ischsemia  of  the  central  artery  is 
caused,  presenting  the  ophthalmoscopic  picture  of 
embolism.  To  produce  this  ophthalmoscopic  appear- 
ance it  is  not  even  necessary  that  the  nerve  should  be 
lacerated ;  it  is  sufficient  that  the  artery  should  be 
torn,  with  or  without  the  vein.  Hirschberg  has 
reported  a  case  of  section  of  the  optic  nerve  in 
which,  in  the  course  of  two  months,  the  retinal 
circulation  became  re-established  at  the  same  time 
as  a  visual  acuity  of  1/20.  It  is  quite  possible  that 
in  this  case  there  was  only  a  lesion  of  the  central 
artery,  and  that  the  retinal  circulation  became  restored 


8G2  FRACTURES  OF  THE  ORBIT 

later  by  a  collateral  circulation  between  retinal 
arteries  and  those  of  the  ciliary  body ;  for  anatomy 
demonstrates  at  the  same  time  the  difficulty,  and 
the  possibility,  of  the  re -establishment  of  the  retinal 
circulation  by  this  mechanism. 

The  gravity  of  such  a  disaster  does  not  need  to  be 
demonstrated.  When  the  artery  and  the  vein  are 
lacerated  the  functions  of  the  retina  are  abolished ; 
and  when  the  optic  nerve  is  seriously  contused  the 
rupture  of  the  nerve  filaments  adds  an  additional 
complication,  and  causes  atrophy  of  the  disc,  a  fatal 
consequence  which  also  follows  destruction  of  the 
vessels  alone. 

The  condition  is  not  so  grave  if  the  contusion  of  the 
nerve  is  so  superficial  as  not  to  interfere  with  the  circu- 
lation in  the  central  artery  and  vein.  It  is  known 
that  the  nerve  can  be  pulled  on  fairly  strongly  without 
the  vessels  suffering ;  indeed,  stretching  of  the  optic 
nerve  has  been  recommended  in  cases  of  atrophy  by 
De  Wecker,  who  hoped  thus  to  restore  the  nutrition 
of  the  nerve  by  stimulating  the  circulation  of  blood  in 
the  vessels  which  it  contains. 

It  is,  however,  rare  for  the  optic  nerve  to  be  pulled 
on  and  bruised  by  a  projectile  without  causing  gross 
damage,  and  consecutive  papillary  atrophy  is  the 
ordinary  result  of  traumatism.  Moreover,  when  the 
foreign  body  is  bulky,  as  in  Case  20,  at  the  same  time 
as  the  optic  nerve  is  bruised,  the  posterior  pole  is  also 
the  seat  of  grave  lesions  (profuse  haemorrhage  in  the 
macular  region,  and  a  veritable  lake  of  blood  in  the 
choroid,  resulting  from  the  rupture  of  a  vessel). 
Radiography  and  Kronlein's  operation  showed  that 
in  this  case  the  projectile  was  behind  the  globe  and 
in  contact  with  the  nerve. 

(c)  Lesion  of  the  nerve  behind  the  site  of  entry  of 
the  vessels. — In  military  surgery  the  optic  nerve  may 
be  wounded  directly  by  a  penetrating  foreign  body, 
or  indirectly  by  a  fracture  radiating  towards  the 
optic  foramen,  where  a  splinter  may  lacerate  it  as  it 
passes  through  the  foramen  opticum. 


PRESERVATION  OF  THE  EYEBALL         8G3 

{d)  Direct  injuries. — These  occur  after  the  entry  into 
the  orbit  of  foreign  bodies,  shrapnel,  fragments  of 
shell,  etc. ;  at  the  same  time  as  the  injury  to  the 
optic  nerve  the  projectile  may  have  grazed  and  more 
or  less  bruised  the  eyeball,  which  may  itself  present 
direct  lesions.  It  may  happen  that  vision  is  only 
partially  destroyed,  and  Gonin  in  his  article  in  the 
Encyclopedie frangaise dOjihtalmologie  (Vol.  VII,  p.  537) 
reports  a  case  in  which,  after  wound  of  the  nerve  by 
a  fragment  of  lead,  there  was  partial  loss  of  vision ; 
that  is,  a  great  exception  to  the  rule  that  injury  to 
the  optic  nerve  by  a  projectile  is  followed  sooner  or 
later  by  complete  atrophy  of  the  nerve. 

8uch  was  our  experience  in  a  case  in  which  the  pro- 
jectile, the  sheathing  of  a  bullet,  was  found  after  a 
Kronlein  operation  in  the  apex  of  the  orbit,  near  the 
sphenoidal  fissure  (Case  21). 

When  the  projectile  is  at  the  apex  of  the  orbit,  in 
contact  with  the  nerve,  in  Cases  22  and  26,  it  may  act 
by  compression  and  bring  about  a  simple  primary 
white  atrophy,  i.  e.  not  neuritic. 

It  may  happen,  further,  that  a  large  projectile 
enters  the  orbit,  comes  to  rest  within  the  muscular 
cone,  without  implicating  the  optic  nerve,  and  leaving 
the  eye  with  good  vision.  This  happened  in  Case  23, 
where  a  shrapnel  ball,  following  a  horizontal  course 
from  without  inwards,  having  perforated  the  external 
orbital  wall  behind  the  eyeball,  came  to  rest  in  the 
cone  of  muscles  IJ  cm.  from  the  posterior  pole  of  the 
eye,  at  a  very  short  distance  from  the  optic  nerve, 
which  remained  intact.  When  the  intra-orbital  foreign 
body  is  outside  the  muscular  cone  the  optic  nerve  is 
much  more  likely  to  remain  unharmed.  This  occurred 
in  Case  20,  where  the  shell  fragment  lodged  above  the 
globe  and  provoked,  by  direct  contusion  of  the  eye- 
ball, serious  damage  in  the  deep  membranes — 
haemorrhage  into  the  vitreous,  choroidal  rupture, 
retinal  detachment.  i   r 

(e)  Indirect  injuries. — These  are  consecutive  to  frac- 
tures.    All  ophthalmic  surgeons  who  have  experience 


864  FRACTURES  OF  THE  ORBIT 

of  industrial  accidents  know  how  frequently  falls  upon 
the  head  and  fractures  of  the  cranium  are  followed 
after  a  certain  lapse  of  time  by  loss  of  vision  on  one 
side.  Here  we  are  dealing  with  those  radiated  frac- 
tures which,  at  the  optic  foramen  and  the  sphenoidal 
fissure,  lead  to  laceration  of  the  vasculo -nervous 
bundle  which  represents  the  hilum  of  the  orbit  and 
the  eye.  It  is  now  a  long  time  since  this  anatomico- 
clinical  theory,  foreseen  by  some  clinicians,  was  shown 
to  be  scientifically  accurate  by  Berlin.  We  have 
proved  that  in  our  cases  these  radiations  were  invariably 
due  to  injuries  to  the  frontal  bone. 

Lesion  of  the  optic  nerve,  moreover,  may  not  be 
very  serious,  and  absolute  blindness  does  not  always 
result.  WiLBRAND  and  Saenger,  out  of  100  cases  of 
unilateral  optic  lesions,  following  cranial  traumatism, 
have  recorded  50  cases  of  complete  and  permanent 
blindness,  4  cases  of  total  blindness  at  the  outset, 
which  terminated  by  complete  recovery,  17  by  partial 
recovery  with  limitation  of  the  visual  field,  and  24 
cases  in  which  the  lesion  of  the  nerve  had  been  partial 
from  the  outset. 

From  this  it  follows  that  one  must  be  very  circum- 
spect as  to  the  prognosis  of  such  lesions,  especially 
when  they  affect  soldiers,  candidates  for  discharge  and 
a  pension,  whose  visual  acuity  is  not  always  easy  to 
determine.  We  have  observed  a  recent  example 
(Case  60),  in  which,  after  severe  injury  to  the  left 
temporal  region,  which  demanded  trephining,  the 
visual  acuity,  by  reason  probably  of  lesion  of  the  left 
optic  nerve,  had  fallen  to  1/10.  The  patient  obsti- 
nately kept  to  this  figure,  when,  by  the  test  of  the 
reversed  image,  we  had  convinced  ourselves  that  it 
was  at  least  1/3. 

In  certain  cases  the  traumatism  is  shown  only  by  a 
central  scotoma.  In  this  case  it  is  well  to  think  of 
compression  of  the  optic  nerve ;  this  compression 
affects  by  preference  the  macular  bundle  whose  delicate 
functions  are  readily  deranged.  Under  such  circum- 
stances probably  there  is  swelling  of  the  optic  nerve, 


PRESERVATION  OF   THE  EYEBALL         865 

or  compression  by  a  profuse  intra -orbital  haemorrhage, 
or  still  more  likely,  haemorrhage  into  the  sheath. 

This  condition  of  haemotoma  in  the  tunics  of  the 
optic  nerve  merits  particular  attention. 

HEMATOMA    OF    THE    8hEATHS    OF    THE    OpTIC   NeRVE 

Is  effusion  of  blood  into  the  sheaths  of  the  optic 
nerve  common  after  the  orbit  has  been  traversed  by  a 
projectile  ? 

Is  the  classic  opthalmoscopic  picture,  consisting  of 
a  brownish  peri -papillary  margin,  often  observed  ? 
These  are  the  two  questions  which  the  military  oph- 
thalmic surgeon  must  put  to  himself,  and  our  answers 
must  be  in  accord  with  the  observed  facts  and  recorded 
cases. 

A  few  words  in  the  first  place  to  set  the  question 
fairly  before  us. 

Magnus  and  De  Wecker  and  several  others  have 
sought  to  define  precisely  the  clinical  and  anatomical 
signs  of  haemorrhage  into  the  sheaths  of  the  optic 
nerve. 

Magnus  set  himself  to  demonstrate  :  (1  that 
haemorrhage  of  the  nerve  is  followed  in  a  few  hours 
by  characteristic  peri -papillary  and  macular  changes ; 
(2)  that  the  haemorrhage  is  accompanied  by  a  nar- 
rowing, more  or  less  marked,  of  the  arteries,  with 
hyperaemia  of  the  veins ;  (3)  that  the  visual  field 
becomes  obscured  from  the  centre  towards  the  periphery 
in  haemorrhage  of  the  nerve. 

To  all  these  signs  Db  Wecker  adds  another  which 
he  considers  to  be  very  important,  viz.  the  appearance 
of  a  peri -papillary  flame -shaped  haemorrhage,  and  of 
minute  haemorrhages  surrounding  the  macula.  He 
agrees,  therefore,  that  effusions  of  blood  in  the  optic 
nerve  extend  to  the  retina,  and  he  even  believes  that 
certain  haemorrhages  of  the  vitreous  come  from  the 
vaginal  spaces  of  the  optic  nerve. 

RoLLET  and  Abadie  support  this  view ;  they 
describe  a  peri -papillary  layer  of  blood  quite  visible 


866  FRACTURES  OF  THE  ORBIT 

with  the  ophthalmoscope,  and  we  find  similar  asser- 
tions in  the  treatises  of  Schweigger  and  Greeff,  of 
DiMMEU,  in  Schmidt-Rimpler's  manual,  etc. 

GoNiN,  who  has  written  a  very  interesting  work  on 
this  subject,  develops  an  opinion  contrary  to  that  of 
Magnus  and  De  Wecker. 

He  is  of  opinion  that  there  is  no  case  which  supports 
these  doctrines  concerning  the  ophthalmoscopic  signs 
of  apoplexy  of  the  optic  nerve.  He  says  that  there  is 
not  a  single  case  on  record  of  this  "  sudden  blindness 
which,  after  presenting  the  picture  of  retinal  ischsemia, 
was  proved  by  autopsy  to  be  due  to  an  effusion  into 
the  sheaths  or  the  substance  of  the  nerve ;  on  the 
other  hand,  there  is  not  a  single  case  of  proved  vaginal 
apoplexy  which  manifested  tTie  ophthalmoscopic  signs 
of  obstruction  of  a  central  artery.*' 

Following  the  same  sequence  of  ideas,  and  in  con- 
firmation of  Gonin's  opinion,  particular  attention 
should  be  given  to  a  remarkable  work  by  Dupuy- 
DuTEMPS  upon  hsematoma  of  the  sheaths  of  the  optic 
nerve  in  meningeal  haemorrhage.  In  an  historical 
essay  of  the  highest  value .  this  author  shows  that 
haemorrhage  of  the  optic  nerve  of  traumatic  origin  is 
due  to  the  penetration  into  the  vaginal  cavity  of 
blood  effused  in  the  craijial  sub-arachnoid  space. 

Histological  study  in,  a  first  case  proves  that  the 
intra-vaginal  hsematoma  does  not  extend  towards  the 
globe  beyond  the  anterior  extreniity  of  the  cavity  and 
does  not  cross  the  scleral  barrier ;  blood  does  not 
penetrate  farther  along  the  trunk  of  the  optic  nerve. 
There  were  certainly  in  this  case  small  islets  of  retinal 
haemorrhage,  but  these  haemorrhages  have  no  direct 
relation  with  the  vaginal  hsematoma  of  the  nerve  of 
special  sense  of  the  eye. 

In  a  second  case,  having  to  do  with  a  spontaneous 
meningeal  haemorrhage,  Dupuy-Dutemps  has  demon- 
strated the  same  precise  anatomical  facts  ;  the  haemor- 
rhage does  not  extend  as  far  as  the  disc ;  it  infiltrates 
the  innermost  fibrous  bundles  of  the  dural  sheath, 
particularly  as  far  as   the   central   vessels,   which  it 


PRESERVATION  OF  THE  EYEBALL         867 

surrounds  with  a  continuous  mantle.  In  these  cases 
the  ophthalmoscopic  signs  are  not  as  Magnus,  De 
Wecker  and  the  classic  authorities  in  general  have 
taught,  those  of  retinal  ischsemia,  but  simply  oedema 
of  the  papilla,  with  dilatation  of  the  veins,  and  retinal 
haemorrhages  which  have  arisen  in  situ,  consecutive 
to  difficulties  in  the  circulation  due  to  the  compression 
of  the  central  vessels. 

Such  are  the  older  teachings  (Magnus,  De  Wecker, 
etc.)  and  the  recent  opinions  (Gonin,  Dupuy-Dutemps) 
concerning  haematoma  of  the  optic  nerve.  We  make 
no  pretension  of  writing  an  historical  essay,  however 
incomplete,  on  the  question,  our  object  being  merely 
to  contrast  the  two  points  of  view,  which  are  still 
sub  judice. 

It  now  remains  only  for  us  to  state  on  which  side 
we  should  range  ourselves,  after  having  observed  a 
considerable  number  of  grave  injuries  of  the  optic 
nerve  which  should  certainly  have  been  frequently 
accompanied  by  haemorrhage  into  the  sheaths.  We 
say,  modestly,  "  which  should  have  been  accompanied," 
because,  as  a  matter  of  fact,  we  have  not  any  histological 
examinations  to  throw  into  the  arena  of  discussion, 
not  having  had,  fortunately,  to  make  autopsies  on  our 
wounded.  It  is,  however^  impossible  that  the  optic 
nerves,  bruised,  lacerated  by  bullets,  or  shrapnel  balls, 
or  irregular  shell  fragments,  which  we  have  observed, 
should  not  have  bled  often  into  their  sheaths,  and, 
clinically  speaking,  we  have  many  times  been  eon- 
fronted  with  traumatic  vaginal  haematomata  of  the 
optic  nerve. 

We  owe  it  to  the  truth  to  state  that  we  have  not 
found  on  a  single  occasion  the  ophthalmoscopic  signs 
and  clinical  symptoms  of  retinal  ischaemia,  and  that 
we  have  never  observed  the  papillary  effusion  of  blood 
upon  which  Abadie  has  insisted.  In  civil  ophthal- 
mology it  has  been  the  same ;  after  having  examjiifeid, 
as  happens  to  all  ophthalmic  surgeons  in  extenslye 
practice,  many  injured  persons  who  have  suddeiily 
lost  the  sight  of  one  or  both  eyes,  we  have  never^seen 


868  FRACTURES  OF  THE  ORBIT 

the  blood  well  up  into  the  eye  from  the  sheaths  of  the 
optic  nerve,  and  we  have  the  impression  that  Gonin 
and  DupuY-DuTEMPS  are  right.  Most  certainly  the 
anatomical  researches  made,  notably  by  the  latter 
author,  count  in  the  debate  for  much  more  than  our 
impressions  as  clinicians,  but  it  is  not  permissible  to 
omit  to  state  that  our  clinical  observations  and  their 
pathological  anatomy  are  in  perfect  accord. 

One  point,  however,  merits  to  be  brought  into  relief, 
I  have  not  found  peri-papillary  hsematomata  and 
intra-ocular  effusions  of  blood  consecutive  to  haemor- 
rhages of  the  optic  nerve,  but  I  have  sometimes  seen, 
a  considerable  time  after  the  traumatism,  the  brownish 
pigmented  ring  of  which  the  classic  authorities  speak. 

I  have  observed  it  recently  in  patients  suffering 
from  serious  injuries  which  caused  at  the  outset, 
without  any  lesion,  a  complete  loss  of  central  visual 
acuity ;  vision  became  re-established  gradually  in  the 
course  of  time. 


Fracture  of  the  right  superior  orbital  margin  ;    haBmorrhage 
into  the  sheaths  of  the  optic  nerve.    (Case  27.) 

P.,  Infantry,  wounded  Jan.  10,  1916,  by  shell-fragments, 
of  which  one  had  caused  a  slight  depression  of  the  right 
.' uperior  orbital  margin,  from  which  it  had  been  extracted. 
According  to  the  patient's  story  the  shell  burst  at  a  dis- 
tance of  about  1  metre,  and  the  explosion  was  followed 
by  {otal  loss  of  vision  of  both  eyes.  The  sight  of  the  left 
eye  returned  twelve  hours  later,  but  the  right  eye  only 
commenced  to  perceive  light  three  weeks  after  the  injury. 

On  his  arrival  acuity  was  as  follows — 

R.  E.         Perception  of  light. 
L.  E.         V  =  3/10. 

No  lesion  of  transparent  media  nor  of  deep  membranes. 
The  visual  field,  taken  Jan.  19,  shows  irregular  contours 
on  the  left  side,  with  peripheral  contraction  and  a  semi- 
annular  para-central  scotoma. 

Condition. — March  3,  1916,  the  pupil  reacted  feebly  to 
light.     There  is  slight  inequality  of  pupils. 


PRESERVATION  OF   THE  EYEBALL        869 

The  accommodation  reflex  exists,  but  is  enfeebled ; 
consensual  more  energetic  in  the  L.  E, 

March  3.— R.  E.         V  =  1/20. 
L.  E.         V  =  4/10. 

On  March  6  there  is  reported  for  the  first  time,  on  the 
temporal  border  of  both  discs,  a  blackish-red  pigmenta- 
tion, bordering  the  scleral  ring,  leading  one  to  think  of  a 
haemorrhage  of  the  sheaths ;  these  pari-papillary  half- 
rings  can  only  be  blood  or  blood  debris,  which  has  taken 
several  months  to  arrive  at  the  disc. 

L.  E.        V  =  4/10. 
R.  E.         V  -  5/10. 

The  visual  field  taken  at  this  date  shows  a  concentric 
shrinking  without  central  scotoma. 

March  27,  1916,  R.  and  L.  E.  Reflexes  normal,  no 
lesions  of  the  fundus,  except  the  pigmentation  reported  on 
March  6,  which  remains  stationary  in  both  eyes. 

Visual  fields  normal.  No  contraction,  no  scotoma,  no 
dyschromatopsia . 

R.  E.         V  =  10/10. 
L.  E.         V  :=  10/10. 

At  this  date  one  may  regard  the  patient  as  having 
recovered.  It  remains  to  be  seen  what  course  will  be 
taken  by  the  pigmentation  of  part  of  the  scleral  ring. 

April  4,  1916.  The  slight  red  pigmentation  bordering 
the  scleral  ring  persists,  but  shows  a  tendency  to  disappear. 

Discharged  April  4,  1916. 

Fracture  of  left  orbit ;  right  macular  choroido-retinitis. 

(Case  28.) 

J.  B.,  Infantry,  wounded  at  V.,  Feb.  29,  1916,  by  shell 
fragment.  Dressed  at  once,  he  was  sent  to  B.  and  Limoges. 
From  his  depot,  July  13,  1916,  on  complaining  of  weaken- 
ing of  the  visual  acuity  of  the  right  eye,  he  was  sent  on 
to  us. 

Condition. — The  existence  of  a  mobile  cicatrix  is  noted, 
not  painful,  4  cm.  long,  in  the  form  of  an  E,  situated  a 
little  above  the  superior  exterior  angle  of  the  left  orbit. 
On  palpation  a  slight  depression  of  the  subjacent  bone  is 
felt  (frontal  fossa  and  orbital  process  of  the  frontal  bone). 


870  FRACTURES  OF  THE  ORBIT 

The  left  eye,  corresponding  with  the  wounded  side,  is 
emmetropic  ;  V  =  10/10.  The  transparent  media  and  the 
deep  membranes  are  intact. 

The  right  eye,  which  has  not  been  bruised,  is,  on  the 
contrary,  the  seat  of  slight  mydriasis,  with  manifest  slowness 
of  action  of  the  photo-motor  reflexes. 

The  ophthalmoscope  shows  no  lesion  of  the  refringent 
media. 

On  a  level,  however,  with  the  external  margin  of  the 
disc  there  is  a  hsemorrhagic  band,  about  1  mm.  broad, 
over  two-thirds  of  the  papillary  circumference.  This 
hsemorrhagic  crescent  in  this  position  suggests  haemorrhage 
into  the  sheaths  of  the  optic  nerve. 

In  the  sub-macular  zone  there  is  also  a  retinal  haemor- 
rhage in  the  shape  of  a  haricot  bean,  with  the  hilum 
upwards,  corresponding  on  perimetric  examination  with 
a  semi-annular  scotoma,  para-ceritral  and  superior  (Fig.  1, 
Plate  I). 

The  visual  acuity  of  this  eye  equals  1/10  barely. 

B.  was  discharged  June  5,  1916,  convalescent.  On  his 
return,  Aug.  5,  his  condition  remained  stationary. 

Fall  on  the  head  from  shell  explosion ;   indirect  lesion  of  optic 
nerve  ;  hsematoma  of  sheath.    (Case  29.) 

B.  C,  Infantry,  wounded  at  Fl.,  Sep.  6,  1916,  by  the 
explosion  of  a  shell  which  threw  him  to  the  ground ;  he 
fell  on  the  back  of  his  neck.  A  few  moments  afterwards, 
the  patient  tells  us,  there  was  a  considerable  hsematoma 
of  the  eyelids  and  conjunctiva.  He  foimd  that  the  sight 
of  the  left  eye  was  damaged  immediately  after  the  injury. 
He  was  evacuated  to  Bourges  a  week  later. 

Oct.  26  he  had  seven  days'  leave.  He  returned  to  his 
depot,  thence  to  Pau,  afterwards  to  Bordeaux. 

Condition. — Dec.  12,  1916,  there  was  pigmentation  from 
tattooing  by  powder  of  the  sclerotic,  and,  at  the  internal 
border  of  the  cornea,  towards  eleven  o'clock,  a  speck 
which  is  probably  consecutive  to  a  traumatic  keratitis ; 
the  anterior  chamber  is  normal,  the  reflexes,  although 
diminished,  are  present. 

The  lens  and  the  vitreous  are  normal ;  the  disc  presents 
an  unusual  aspect.  In  the  peri -papillary  region  there  is 
an  abnormal  pigmentation  of  brownish  colour,  especially 


PRESERVATION  OF  THE  EYEBALL 


871 


well  marked  on  the  internal  border  (inverted  image). 
(Fig.  36.) 

In  the  inferior  internal  portion  of  the  disc  there  is  a 
notch ;  it  seems  as  if  in  this  position  the  pigmentation 
overlaps  the  border  of  the  disc. 

The   rest    of   the   papilla   appears   normal,    the    vessels 


Fig.  36. — Peripapillary  hsematic  pigmentation  of 
traumatic  origin. 


having  their  physiological  calibre.  The  macula  presents  a 
slightly  congested  aspect  and  is  clearly  differentiated  from 
the  rest  of  the  fundus.     It  is,  however,  probably  normal. 


R.  E. 
L.  E. 


V  =  10/10. 

V  =  2/10. 


In  this  case  we  think  that  a  traumatic  haemorrhage 
of  the  optic  nerve  has  caused  compression  of  the  macu- 
lar bundles,  and  that,  little  by  little,  the  compression 


872  FRACTURE^;  OF   THE  ORBIT 

has  disappeared  in  proportion  as  the  haemorrhage  has 
been  absorbed. 

The  formation  of  this  pigmented  ring  is  not  due 
to  the  propagation  of  the  haemorrhage,  but  to  the 
migration  of  haematic  pigment ;  and  in  the  discussion 
which  took  place  at  the  Societe  d"Ophtalmo]ogie  de 
Paris,  in  1913,  on  the  subject  of  Dupuy-Dutemps' 
work,  Kalt  very  rightly  remarked  that  the  production 
of  this  pigmented  ring  could  be  quite  well  brought 
into  accord  with  the  anatomical  reports  of  Dupuy- 
DuTEMPS.  The  propagation  of  an  effusion  of  blood  and 
the  migration  of  blood-pigment  after  the  resorption 
of  haemorrhage  are  very  different  matters :  the  second 
might  occur  without  the  first. 

There  is  a  nutritive  current  going  from  the  optic  nerve 
towards  the  eye  which  is  perfectly  capable  of  carrying 
the  pigment  from  behind  forwards  and  of  depositing 
it,  on  its  entry  into  the  eye,  in  the  cribriform  plate 
and  in  the  choroidal  zone  which  immediately  surrounds 
the  disc.  It  appears  to  us  that  this  pigmented  ring 
should  always  be  regarded  as  the  sign  of  an  old  haema- 
toma  of  the  optic  nerve,  and  several  times  amongst 
our  wounded  cases  we  have  been  able  to  give  it  this 
signification  (Fig.  36;  Plate  L  Figs.  1  and  2). 

B. — Lesions  of  the  Vessels.     Traumatic 

HEMORRHAGES    INTO    THE    OrBIT 

Traumatic  effusions  into  the  orbit  have  been  known 
since  Carron  du  Villards,  who  well  defined  conse- 
cutive exophthalmos  as  "  a  compression  and  a  hernia 
of  the  eye."  He  reports,  the  case  of  an  unfortunate 
colleague  who  died  after  a  fall  on  the  pavement ;  at 
the  autopsy  there  was  found  "  a  fracture  of  the  orbit 
near  the  optic  foramen,  the  ophthalmic  artery  and  vein 
having  been  ruptured ;  the  eye  was  thrust  forward  by 
an  enormous  clot  of  blood." 

Accoucheurs  have  long  noted  intra-orbital  effusions 
after  the  application  of  the  forceps,  and  in  all  the 
classic  works  on  ophthalmology  we  find  very  precise 


PRESERVATTON  OF   THE   EYEBALL          87:3 

indications  on  the  subject  of  orbital  haemorrhage. 
Mackenzie  mentions  a  very  interesting  case  of  intra- 
orbital hsemorrhage,  accompanied  by  abundant  epis- 
taxis  and  ending  in  death.  Desmarres,  in  his  chapter 
on  affections  of  the  orbit,  speaks  of  tumours  produced 
by  the  extravasation  of  blood  in  the  cellular  tissue 
{Tumeurs  de  VOrhite,  Vol.  I,  p.  230). 

Demarquay  describes  in  his  Traite  des  Tvmeurs 
de  VOrhite  {a)  effusions  of  blood,  following  fracture; 
(6)  effusions  of  blood,  following  wounds;  (c)  effusions 
of  blood,  following  contusion  ;  [d)  spontaneous  effusions 
of  blood. 

On  the  subject  of  traumatic  effusions  of  blood,  the 
only  class  which  interests  us,  he  recalls  the  cases  of  the 
authors  we  have  just  mentioned  and  gives  several 
unpublished  cases  of  his  own,  notably  the  case  of  a 
young  man  of  sixteen  who,  falling  from  the  mast  of  a 
ship  upon  the  deck,  had  such  an  intra-ofbital  hsemor- 
rhage that  the  eye  came  out  of  the  orbit  and  hung  over 
the  nose  immediately  after  the  accident.  The  visual 
function  was  completely  lost,  but  the  eye  completely 
resumed  its  place  after  some  months,  without,  surgical 
interference. 

De  Wecker  devotes  a  chapter  to  haemorrhages 
into  the  orbit,  and  distinguishes  two  classes  of  trau- 
matic haemorrhages :  those  which  are  produced  by 
direct  lesions  and  those  which  are  the  result  of  in- 
direct. He  expressly  mentions  projectiles  amongst  the 
causes. 

The  authors  who  have  written  on  the  subject  disagree 
entirely  as  to  the  relative  frequency  of  this  kind  of 
accident.  According  to  Carron  d.u  Villards  it  is 
very  common  in  injuries  of  the  orbit;  according  to 
Berlin  it  is  very  rare.  According  to  our  casejs  the  first 
author  is  right,  since  all  our  orbital  cases,  wounded  by 
projectiles  of  war,  presented  in  the  early  period  of  their 
injury  exophthalmos  more  or  less  pronounced,  which 
must  obviously  be  attributed  to  an  effusion  of  blood,  in 
many  cases  very  abundant. 

The   source  of  this  intra-orbital  effusion   of    blood 


874  FRACTURES  OF  THE  ORBIT 

varies ;  it  may  come  from  the  vessels  of  the  orbit  or 
surrounding  parts,  or  from  the  intra-cranial  vessels. 

The  haemorrhages  arise  sometimes  from  an  injury  to 
the  ophthalmic  artery  or  vein,  and  it  is  by  such  injuries 
that  one  can  explain  the  appearance  of  an  aneurism  at 
a  later  stage.  As  a  rule  the  blood  which  is  poured  out 
behind  the  eye  comes  from  a  lesion  in  the  trunk  itself 
or  from  one  of  the  important  vessels  at  the  posterior 
part  of  the  orbit.  Sometimes,  however,  the  extravasa- 
tion of  blood  begins  in  the  cellular  tissue  of  the  eyelids 
and  works  backwards,  passing  from  the  superficial 
to  the  deep  portion  of  the  orbital  cavity.  Further,  in 
the  greater  number  of  cases,  the  cause  of  the  haemor- 
rhage cannot  be  exactly  located.  That  is  precisely 
the  position  in  which  we  find  ourselves  with  regard  to 
our  patients,  for  they  have  all  recovered,  and  hence  we 
have  not  been  able  to  study  the  anatomical  condition 
in  detail. 

We  must  compare  with  these  traumatic  intra-orbital 
haemorrhages  those  which  sometimes  result  from  a  too 
free  tenotomy  and  those  which  happen  after  a  Kron- 
lein's  operation,  or  simply  after  an  enucleation  in  which 
the  operator's  scissors  have  strayed  behind  Tenon's 
capsule. 

Sometimes  the  blood  comes  from  fractured  bones ; 
the  bones  of  the  orbit  are  in  certain  places  thick  and 
richly  vascularised  by  the  vessels  which  run  either  in 
the  diploe  or  in  the  compact  tissue.  When  ruptured 
they  bleed  into  the  orbit,  and  must  often  be  the  cause 
of  the  haematomata  met  with  in  our  patients.  The 
haematomata  of  the  orbit  in  the  newly  born,  delivered 
by  means  of  forceps,  have  generally  a  haemorrhage  of 
bony  origin  as  their  cause. 

When  the  blood  comes  from  intra-cranial  vessels 
it  may  enter  the  orbit  in  several  ways,  according  to 
J.  RoLLET,  who  wrote  an  excellent  account  of  the  sub- 
ject. Sometimes  it  passes  through  a  fissure  in  the 
fractured  orbital  vault,  thus  bringing  the  blood  extra va- 
sated  beneath  the  pia  mater  into  communication  with 
the  orbital  chamber.    In  this  case  not  only  the  vessels 


PRESERVATION  OF  THE  EYEBALL        875 

of  the  pia  mater,  but  also  the  vessels  of  the  brain  bleed. 
In  certain  fractures  of  the  orbit,  of  which  we  shall 
report  cases  later,  the  frontal  lobe  is  reduced  to  a  pulp ; 
above  the  orbit  a  large  aperture  establishes  free  com- 
munication between  the  cranial  and  orbital  cavities, 
and  we  find  behind  the  eye  a  blackish  mass  continuous 
with  the  brain. 

In  other  cases  extravasation  of  blood  takes  place 
under  the  detached  dura  mater  and  extends  into  the 
coverings  of  the  optic  nerve.  There  are,  further,  cases 
in  which  a  splinter  of  bone,  detached  from  the  orbital 
wall,  has  wounded  a  meningeal  vessel.  Mackenzie, 
again,  quotes  a  case  of  comminuted  fracture  of  the 
orbital  vault,  which  lacerated  the  cavernous  sinus,  and 
produced  in  consequence  a  very  large  effusion. 

Again,  the  blood  rnay  reach  the  orbit  through  a  natu- 
ral aperture,  the  optic  foramen,  follow  the  sheath  of  the 
optic  nerve  and  produce  an  intra -orbital  haemorrhage, 
at  the  same  time  as  a  haematoma  of  the  nerve-sheaths, 
the  subject  with  which  we  were  dealing  above. 

Moreover,  to  J.  Rollet  is  due  the  merit  of  having 
been  the  first  to  point  out  orbital  haemorrhage  by  contre- 
coup. 

Finally,  blood  may  also  come  from  the  nasal  cavities 
and  sinuses.  It  is  not  rare  in  orbital  fractures  for  the 
orbital  wall  to  be  staved  in.  The  mucous  tissues  of  the 
nose,  very  richly  vascular,  almost  erectile,  bleed  at  the 
same  time  into  the  nasal  fossae  and  into  the  orbit ;  the 
frontal  sinus  is  less  vascular,  but  when  it  accidentally 
communicates  with  the  orbit,  it  may  also  fill  it  with 
blood.  Similarly  the  maxillary  sinus  when  seriously 
injured  may  become  filled  with  blood,  which  overflows 
into  the  orbital  cavity. 

Symptoms. — The  chief  symptom  is  exophthalmos ; 
the  accessory  symptoms  are  subconjunctival  ecchymo- 
sis  and  infiltration  of  the  eyelids. 

The  exophthalmos  is  remarkable  for  the  rapidity 
of  its  development.  It  is  direct — that  is,  the  eyeball 
is  thrust  forwards  almost  as  if  it  were  a  question  of  a 
tumour  of  the  optic  nerve ;  it  is  easily  reducible,  and 


876  FRACTURES  OF   THE  ORBIT 

becomes  more  marked  when  the  patient  leans  the  head 
forwards.  The  circumstances  under  which  it  lias 
occurred  scarcely  permit  of  any  error  in  diagnosis. 

Subconjunctival  ecchymosis  may  occur,  even  when 
there  is  no  exophthalmos — that  is  to  say,  when  the  very 
moderate  intra-orbital  haemorrhage  merely  suffuses 
the  tissues.  The  fluid  blood  slowly  spreads  through 
the  orbital  tissues  as  far  as  the  conjunctiva,  wliich 
becomes  ecchymosed  only  after  the  lapse  of  time, 
twenty-four  to  forty-eight  hours,  or  sometimes  more. 
It  is  one  of  the  classic  signs  of  fracture  of  the  cranium 
which  has  been  studied  by  (^uesnay  in  the  MemoireH 
de  I  Academie  de  Chirurgie  and  demonstrated  by 
Velpeau.  Its  delayed  appearance  in  fractures  of  the 
orbit  from  projectiles  of  war  indicates  a  fracture  of  the 
base  of  the  skull. 

It  is  well,  moreover,  to  distinguish  clearly  between 
the  outpouring  of  blood  which  results  from  a  fracture  of 
the  orbit  and  that  which  follows  a  direct  contusion  of 
the  soft  parts.  We  are  again  indebted  to  J.  Rollet  for 
a  valuable  article  in  which  he  has  established,  (1)  that 
ecchymosis  due  to  a  fracture  spreads  by  degrees ; 
(2)  that  it  is  limited  to  the  conjunctiva  and  its  pal- 
pebral folds ;  (3)  that  it  produces  only  a  moderate 
amount  of  tumefaction  :  whereas  that  which  follows  on 
contusion  is  very  rapid  in  its  onset,  spreads  to  the  soft 
parts  of  the  face,  and  readily  assumes  large  proportions. 

Hence,  when  we  find  (as  in  Cases  17,  20,  21,  etc.) 
well-marked  exophthalmos  and  profuse  ecchymosis  we 
must  regard  them  as  due  to  lesions  of  the  soft  parts 
with  laceration  of  the  orbital  vessels. 

When  there  is  no  infection  of  the  wound  haemorrhage 
is  often  absorbed  quickly,  the  exophthalmos  disap- 
pears, and  the  visual  functions  are  restored  in  propor- 
tion as  the  optic  nerve  and  the  sensori-motor  apparatus 
have  remained  intact.  But  it  may  happen  that  the 
orbital  wound  becomes  mfected  ;  orbital  cellulitis  then 
ensues,  by  no  means  a  negligible  complication.  It 
must  be  pointed  out,  however  that  this  infection  i& 
quite  rare.     Perhaps  the  patients  attacked  with  it  do 


PRESERVATION  OF   THE  EYEBALL        «77 

not  get  as  far  as  our  hospital  and  have  been  treated  at 
the  front.  It  is  remarkable,  however,  to  note  amongst 
the  hundreds  of  fractures  of  the  orbit  which  we  have 
examined  the  smallness  of  the  number  of  those  compli- 
cated by  infective  cellulitis  of  the  orbit.  We  have  only 
seen  two  cases,  which  may  be  summed  up  thus : 

In  the  first  patient  a  bullet  penetrated  at  the  level 
of  the  left  zygomatic  arch  and  emerged  by  the  left  orbit, 
rupturing  the  eyeball,  which  was  enucleated  the  day 
following  the  injury.  When  he  came  under  our  care,  six 
days  later,  he  pres'?nted  all  the  signs  of  orbital  cellulitis 
(extreme  oedema  of  the  lids,  voluminous  chemosis, 
conjunctival  suppuration) ;  further,  the  signs  of  menin- 
geal reaction  were  present  (Kernig's  sign,  slow  pulse, 
temperature  386°  C.  (101-2°  Fahr.)  vomiting).  Alum- 
bar  puncture  proved  negative  ;  incision  and  drainage  of 
the  orbital  cavity,  with  the  application  of  ice  to  the  head, 
brought  the  infection  under  control,  and  recovery 
rapidly  followed. 

The  second  patient  was  struck  by  a  shell  fragment 
which  penetrated  at  the  level  of  the  root  of  the  nose  on 
the  right  side,  traversed  the  right  lacrymal  sac,  the 
nasal  fosssc,  the  left  orbit,  and  finally  lodged  in  the  left 
temporal  region.  The  eye  w^as  in  a  condition  of  exoph- 
thalmos, and  ophthalmoscopic  examination  showed 
detachment  of  the  papillo-macular  region  of  the  retina. 
Three  weeks  after  admission  orbital  cellulitis  appeared  ; 
an  incision  through  the  external  wall  permitted  the 
escape  of  a  large  quantity  of  foetid  pus  ;  there  was 
osteo-periostitis  of  the  orbital  wall.  Recovery  was 
very  slow,  and  on  Dec  31  the  patient  showed  signs 
of  suppurating  ethmoiditis,  which  necessitated  his 
removal  to  the  rhinological  department.  Jan.  13,  he 
was  returned  to  us  as  an  urgent  case,  the  orbital 
infection  having  returned  ;  we  then  noted  the  evidences 
of  meningeal  reaction  (Kernig's  sign,  vomiting,  tem- 
perature 38-4°  C.  (Fahr.  100-6°). 

The  general  symptoms  rapidly  grew  worse,  and  we 
made  a  lumbar  puncture  which  yielded  almost  pure 
pus.     Jan.    22,    the   patient   died,    probably   from   a 


878  FRACTURES  OF   THE  ORBIT 

cerebral  abscess  previously  latent,  opening  secondarily 
into  the  meninges,  consequent  upon  infection  of  the 
encephalon  through  the  orbital  aperture. 

Orbital  cellulitis  is  therefore  an  exceptional  compli- 
cation .  We  explain  its  rarity  by  suggesting  that  usually 
the  bullet  or  fragment  of  shell  which  enters  the  orbit 
does  not  carry  with  it  shreds  of  dirty  clothing,  and 
that  the  orifice  of  entry,  usually  very  small,  closes  spon- 
taneously sufficiently  quickly  to  escape  the  dangers 
which  may  attack  a  wounded  man  who  does  not  obtain 
immediate  attention. 

When  the  instrument  of  trauma  is  not  infected  or 
such  as  is  capable  of  infecting  the  orbital  cavity,  it 
may  happen  sometimes  that  infection  proceeds  from 
the  fractured  nasal  fossae,  which  freely  communicate 
with  the  focus  of  haemorrhage.  We  have  recently 
seen  an  example,  which,  although  it  is  not  a  war  case, 
merits  none  the  less  to  be  reported  here. 

A  boy  aged  eleven,  when  running,  fell  suddenly  on 
his  nose ;  there  was  immediate  epistaxis  and  very 
marked  exophthalmos,  indicating  intra-orbital  haemor- 
rhage from  rupture  of  some  important  vessels ;  six 
days  later  inflammatory  complications  appeared  (fever, 
great  pain,  well-marked  and  painful  swelling  at  the 
angle  of  the  eye,  above  the  lacrymal  sac).  It  soon 
became  evident  that  a  large  purulent  collection  had 
formed  behind  the  eye ;  it  was  necessary  to  incise  and 
drain.  This  procedure  resulted  in  rapid  and  uninter- 
rupted recovery.  It  is  quite  probable  that  infection 
of  the  orbital  pocket  of  blood  resulted  from  the  fracture 
of  the  OS  planum  and  laceration  of  the  mucous  mem- 
brane of  the  nasal  fossae.  Thus  the  infection-carrjdng 
substance.^  from  the  nose  penetrated  into  the  orbit. 

It  would  be  natural  to  expect  that  in  fractures  of  the 
orbit  by  projectiles  of  war,  in  which  the  nasal  fossae  and 
the  nose  are  largely  involved  and  put  in  communication 
with  the  orbital  chamber,  such  an  infection  would  be 
frequently  produced.  We  are  bound  to  admit  that  it 
is  not  so,  and  that  in  practice  this  complication  is  very 
rare. 


PRESERVATION   OF   THE  EYEBALL       879 

What  we  have  observed  concerning  intra-orbital 
haemorrhages  amongst  our  cases  nearly  always  consists 
in  a  rapidly  formed  and  well-marked  exophthalmos, 
which  yields  little  by  little  to  the  influence  of  time  with- 
out resulting  in  permanent  damage. 

When  fracture  implicating  the  orbital  vault  allows 
of  free  communication  between  the  orbital  chamber 
and  the  brain  events  happen  due  to  the  cerebral  lesion 
itself  ;  some  interesting  cases  of  this  will  be  given  later. 

C. — Traumatic  Lesions  of  the  Extrinsic  and 
Intrinsic  Muscles 

A  certain  number  of  cases  are  reported  of  paralyses 
of  muscles  of  the  eye  due  to  contusions  and  to  orbital 
injuries.  All  instruments  of  violence,  whether  cold 
steel  or  projectiles,  may  implicate  more  or  less  gravely 
the  recti  and  oblique  muscles  of  the  eye ;  the  muscle  is 
thrust  against  the  orbital  wall  and  crushed.  Bernheim 
quotes  the  case  of  a  child  who,  flinging  himself  against 
a  door,  ruptured  the  internal  rectus  near  its  bulbar 
insertion. 

Pan  as,  in  1902,  collected  the  published  cases  of 
traumatism  of  the  ocular  muscles,  and  remarked  that 
the  chief  agents  were  contusions,  accidents  with  foils, 
horns  of  cattle,  blows  against  hard  substances,  doors, 
sticks,  etc. 

The  pathological  anatomy  of  these  muscular  ruptures 
is  not  exactly  known,  for  usually  the  surgeon  inter- 
venes too  late,  when  the  repair  is  already  effected.  In 
two  cases  only,  one  by  Panas  and  one  by  Graefe,  the 
muscle  was  torn  at  its  insertion  into  the  sclerotic.  It 
is  probable  that  in  other  cases  the  rupture  occurred 
in  the  muscle  itself.  There  is  good  reason  for  this 
view  in  that  traumatic  muscular  paralysis  is  usually 
direct — that  is,  the  muscle  itself  is  contused  or  crushed, 
hence  it  is  there  that  the  solution  of  continuity  should 
occur.  Besides,  ruptures  of  muscles  are  produced, 
as  is  demonstrated  by  the  general  surgeons,  sometimes 
in  the  fleshy  portion,  sometimes  in  the  tendon,  according 


880  FRACTURES  OF   THE  ORBIT 

as  the  muscle  is  injured  at  the  moment  of  contraction 
or  at  the  moment  of  relaxation.  Malgaigne,  taking 
the  idea  from  Delpech,  carried  out  some  noteworthy 
experiments  in  connection  with  this  subject.  "  Muscu- 
lar rupture,"  he  says,  "  only  takes  place  when  the 
muscle  is  stretched  and  elongated,  rupture  of  tendon 
when  the  muscle  is  shortened  and  contracted."  So  far 
as  concerns  the  muscles  of  the  eye  there  is  no  reason 
for  refusing  to  accept  this  opinion  of  the  general 
surgeons. 

Since  the  work  of  Panas,  Garipuy  and  Demicheri 
have  published  cases  of  paralysis  of  the  superior  oblique, 
and  Terrien  has  reported  a  case  of  partial  paralysis 
due  to  an  effusion  of  blood  which  filled  the  cavity  of 
the  left  maxillary  sinus. 

Terson  and  Cosmetatos  have  published  similar 
cases. 

Sometimes  the  injury  causes  an  effusion  of  blood 
into  the  sheath  of  the  muscle  ;  paralyses  by  intra- 
muscular hsemorrhage  (De  Lapersonne)  are  produced 
in  this  manner.  We  do  not  dAvell  upon  this  subject 
because  we  do  not  wish  to  pass  in  review  all  the 
published  cases ;  it  will  suffice  if  we  place  on  record, 
here  those  which  we  have  observed,  and  which  are  as 
follow : — 

We  have  noted  seventeen  cases  of  this  kind.  The  seat 
of  the  orbital  fracture  is  in  immediate  proximity  to 
the  muscle  attacked ;  we  draw  particular  attention 
to  fractures  of  the  roof,  which  were  accompanied  nine 
times  by  paralysis,  either  of  the  levator  palpebrse, 
or  the  rectus  superior,  or  both  together.  In  four  of  our 
cases  paralysis  of  the  inferior  rectus  alone  coexisted 
with  a  depression  of  the  median  portion  of  the  inferior 
orbital  margin.  Another  patient,  after  an  infero- 
internal  wound  of  the  orbit,  was  affected  with  diplopia 
due  to  paralysis  of  the  inferior  oblique.  In  another  case 
the  external  rectus  was  traversed  by  a  revolver  bullet. 
Finally,  we  cite  two  cases  of  detachment  of  the  pulley 
of  the  superior  oblique  following  a  smash  of  the  corre- 
sponding frontal  sinus. 


PRESERVATION  OF  THE  EYEBALL        881 

In  four  other  case»  it  is  more  plausible  to  admit  the 
hypothesis  of  a  fracture  radiating  to  the  apex  of  the 
orbit.  These,  after  a  depressed  fracture  of  the  frontal 
bone  or  of  the  supero-Csxternal  angle  of  the  orbit,  had 
several  extrinsic  muscles  paralysed  at  the  same  time. 
We  may  suppose  that  a  lesion  of  the  nerve  filaments 
themselves  at  their  entry  into  the  orbit  had  occurred, 
for  this  best  explains  the  multiplicity  of  symptoms 
These  four  cases  may  be  summed  up  in  this  manner — 

(a)  Paralysis  of  the  superior  rectus  and  the  levator 
palpebrae,  with  internal  ophthalmoplegia. 

(b)  Paralysis  of  the  superior  rectus,  the  levator 
palpebrse,  and  the  internal  rectus,  with  internal 
ophthalmoplegia. 

(c)  Paralysis  of  the  superior  rectus,  the  internal 
rectus,  and  the  inferior  oblique. 

{d)  Paralysis  of  the  superior  rectus,  the  inferior 
rectus,  and  the  superior  oblique. 

Finally  should  be  mentioned  two  cases  of  paralysis, 
one  of  the  superior  rectus,  the  other  of  the  superior 
oblique,  consecutive,  one  to  a  bullet  going  to  the  apex 
of  the  orbit,  the  second  to  a  fracture  of  the  fronto- 
temporal  region  after  a  fall  on  the  head,  in  which  the 
nerve-trunk  alone  seems  to  have  been  involved. 

lyitrinsic  muscles. — In  reviewing  the  action  of  gross 
injuries  of  the  orbit  upon  the  intrinsic  muscles  of  the 
eye  no  one  will  be  surprised  if  we  give  a  considerable 
number  of  examples.  We  have  very  frequently  ob- 
served paralj^sis  of  the  sphincter  and  the  mydriasis 
which  results  from  it,  a  very  real  mydriasis,  attributable 
to  rupture  of  the  muscular  fibres,  and  only  very  rarely 
accompanied  by  paralysis  of  the  accommodation. 

,  The  mechanism  of  traumatic  mydriases,  by  direct 
shock  upon  the  eye,  is  well  known,  and  when  the  pro- 
jectile has  touched  the  eyeball  tangentially  it  is  not 
surprising  that  such  a  phenomenon  should  occur.  But 
when  the  projectile  has  not  touched  the  eye  the  case 
is  more  interesting  and  merits  attention. 

We  have  met  with  two  cases  of  this  kind  amongst  the 
wounded   who   had   fracture   of   the   superior  orbital 


882  FRACTURES  OF  THE  ORBIT 

margin ;  they  presented  no  lesion  of  the  ocular  mem- 
branes, and  visual  acuity  was  preserved ;  hence  we  had 
to  ascribe  this  paralysis  of  the  pupillary  and  ciliary 
muscles  to  concussion. 

We  now  come  to  the  affections  which  implicate 
the  eye  itself.  We  shall  consider  successively  those 
which  occur — 

(1)  In  the  transparent  media. 

(2)  In  the  deep  membranes,  where  we  shall  make 
two  subdivisions,  (a)  lesions  of  the  uveal  tract,  (6) 
lesions  of  the  retina. 


D. — Lesions  op  the  Eyeball 

(1)  Affections  of  the  Transparent  Media 

Cataracts  from  Contusion  and  Concussion  of  the  Lens 

Opacification  of  the  crystalline  lens,  consecutive 
to  contusion  of  the  lens  without  rupture  of  the  capsule, 
is  incontestable.  It  is  not  even  rare,  so  that  Arlt, 
Liebreich,  Desmarres  and  Warlomont  were  wrong 
in  doubting  it.  De  Wecker,  Berlin,  Becker  and 
FucHS  have  demonstrated  its  existence  both  clinically 
and  by  experiment.  The  last  author  has  written  a 
remarkable  essay  upon  the  subject ;  he  describes  three 
types  of  anterior  polar  lesions. 

(1)  Starred  form,  with  rays  in  arranged  sectors, 
increasing  in  thickness  towards  the  periphery. 

(2)  Rays  terminating  in  a  point  towards  the 
periphery. 

(3)  Arrangement  in  the  form  of  leaflets. 

These  aire  superficial  epithelial  troubles,  capable  of 
disappearing.  Lesions  of  the  posterior  pole  are  more 
serious  and  are  dissipated  with  difficulty ;  is  it  possible 
that  there  is  in  this  case  a  delicate  invisible  laceration 
of  the  capsule  in  the  hyaloid  fossa  ? 

It  is  certainly  not  impossible,  and  it  is  the  opinion 
to  which  BoNNEFON,  who  has  made  an  interesting  study 
of  the  question,  is  inclined. 


PRESERVATION  OF  THE  EYEBALL      883 

This  author  thinks  that  in  the  affections  of  the  ante- 
rior pole  of  which  Fuchs  speaks  it  is  a  question  of 
epitheUal  disorders  not  affecting  the  lens  fibres.  The 
normal  unions  of  the  various  parts  of  the  lens  become 
separated,  but  there  is  no  cataract  properly  so  called ; 
if  the  striae  persist,  they  are  situated  at  the  site  of 
dislocation  of  the  fibres,  and  he  believes  that  when  a 
rapidly  developing  cataract  is  produced  after  a  contusion 
there  exists  a  rupture  of  the  capsule. 

We  have  observed,  clinically,  cases  which  agree  well 
with  Bonnefon's  opinion  ;  we  have  a  very  clear  recol- 
lection of  a  patient  who,  after  a  contusion  of  the  eyeball, 
presented  at  the  posterior  pole  a  star-shaped  cataract 
which  seemed  likely  to  progress  rapidly.  This  was  an 
error  in  prognosis,  for  the  polar  and  stellar  opacity  be- 
came absorbed.  It  is  quite  possible,  in  fact,  as  Bonne- 
FON  thinks,  that  posterior  polar  cataract  may  become 
absorbed  when  there  is  no  rupture  of  the  capsule,  and 
on  the  contrary,  will  become  complete  when  a  rupture 
exists,  however  small  this  may  be.  We  need  not  allow 
ourselves  to  be  disturbed  by  the  objections  of  those  who 
quote  as  argument  for  cataract  without  rupture  what 
happens  in  experimental  (naphthalin)  cataract.  There 
it  is  a  question  of  disturbance  of  the  lens  analogous 
to  that  in  spontaneous  cataract,  which  depends  evi- 
dently upon  an  alteration  of  nutrition,  more  or  less 
unknown,  and  which  has  nothing  in  common  with 
traumatic  cataract. 

But  still  more  interesting  are  the  cases  consecutive 
to  air  concussion — what  the  old  writers  called  "  the 
wind  of  the  cannon-ball." 

We  have  seen  several  typical  cases,  notably  two 
instances  reported  by  our  assistant,  De.  Harriet, 
which  deserve  to  be  placed  on  record,  because  they  are 
two  very  clear  examples  of  lens  opacity,  of  true  cata- 
racts, due  to  the  shock  of  aerial  waves  on  the  eyeball  : 
two  men,  walking  side  by  side  upon  the  same  level 
were  violently  thrown  to  the  ground  by  the  bursting 
of  a  shell.  In  addition  to  superficial  injuries  and 
slight  contusions,  both  immediately  complained  of  a 


884  FRACTURES  OF   THE  ORBIT 

sensation  of  burning  in  the  eye  and  of  a  slight 
diminution  of  sight. 

Nine  days  after  the  traumatism  these  cases  pre- 
sented, besides  traumatic  mydriasis,  a  star-shaped 
posterior  polar  catp.rg.ct ;  the  branches,  to  the  number 
of  six,  very  irregular  in  one  case,  a  little  more  marked 
in  the  inferior  portion  in  the  other,  occupied  the 
posterior  pole  of  the  lens.  Three  months  later  the 
cataracts,  evolving  normally,  were  almost  complete. 

The  offending  agent  here  was  the  concussion  of  the 
aerial  waves  produced  by  the  explosion  of  the  shell, 
and  it  is  probable  that  the  posterior  capsule  was  the 
seat  of  a  small  laceration. 

We  do  not  dwell  upon  these  two  cases,  which  do 
not  strictly  belong  to  fractures  of  the  orbit ;  we  have 
drawn  attention  to  them  on  account  of  the  analogy 
which  they  present  to  cataracts  produced  by  the  con- 
cussion imposed  by  projectiles  upon  neighbouring  parts 
of  the  eye. 

We  are  able  to  report  three  examples  of  these  cata- 
racts by  concussion,  due  to  traumatism  in  the  neigh- 
bourhood of  the  eye. 

One  case  had  a  fracture  of  the  right  temporal  bone, 
with  cerebral  pulsation  perceptible ;  the  right  eye  had 
an  intumescent  cataract,  and  the  excellent  light 
reflexes  allowed  us  to  conjecture  that  the  deep  mem- 
branes were  intact. 

The  second  case  also  had  an  intumescent  cataract 
of  the  right  eye,  with  preservation  of  the  globe,  with- 
out injurv  to  the  media,  an  affection  consecutive  to  a 
fracture  of  the  superior  margin  of  the  orbit  by  a 
fragment  of  shell. 

In  the  third  case,  with  a  fracture  of  the  supero- 
extemal  angle  of  the  orbit,  there  was  iridodialysis  on 
the  side  of  the  bony  depression  and  total  cataract. 
Examination  of  the  reflexes,  however,  indicated  that 
there  was  serious  damage  to  the  choroid  and  retina 
(ha3morrhage  or  detachment). 

It  follows  from  what  has  just  been  said,  and  par- 
ticularly from  our  cases,  that  we  cannot  accept  the 


PRESERVATION  OF   THE   EYEBALL        885 

conclusion  of  Egner,  admitted  by  Dor  (Encydopedie 
frangaise  d'Opktahnologie,  Vol.  VII,  p.  13):  "Cataracts 
by  simple  contusion  can  no  longer  be  considered  as  a 
rarity,  whilst  cases  of  rupture  of  the  capsule  by  simple 
contusion  are  rare." 

What  do  these  authors  know  about  it,  and  upon 
what  are  they  basing  their  assertion  concerning  the 
rarity  of  capsular  laceration  ? 

In  the  cases  of  concussion  by  displacement,  such  as 
those  which  we  report,  where  it  seems  at  first  sight 
that  the  capsule  should  have  been  spared,  nothing  is 
less  certain,  since  we  know  that  the  shock  of  an  aerial 
wave  is  capable  of  dislocating  a  lens  or  rupturing  the 
uveal  tract — why  should  it  not  be  able  to  rupture  the 
lens  capsule  1 

We  are  of  opinion,  with  Bonnefon,  that  the  anterior 
epithelial  mischief  and  the  disturbances  of  the  various 
segments  dislocated  backwards  are  susceptible  of 
absorption  when  the  capsule  is  not  ruptured  :  there  is 
no  true  cataract  in  such  cases.  When  the  cataract 
progresses  and  becomes  complete,  it  is  probable  that 
the  capsule  is  torn  somewhere  near  the  part  which 
earliest  becomes  opaque. 

Subluxation  and  Jjuxation  of  the  Lens 

We  have  observed  several  cases  presenting  no 
essential  differences  from  lesions  of  the  same  order 
which  are  common  enough  in  civil  practice,  notably 
in  occupational  accidents.  We  will  quote  only  one 
case,  concerning  a  luxation  of  the  lens  upwards,  which 
remained  for  some  months  suspended  by  a  narrow 
band  of  the  suspensory  ligament  without  falling  into 
the  vitreous.  In  saying  that  such  lenses  are  not  the 
seat  of  cataract  we  are  saying  nothing  out  of  the 
common,  because,  in  this  case,  the  force  which  loosened 
the  lens  met  with  no  resistance,  and  the  lens  escaped 
without  contusion. 

A  more  interesting  fact  from  the  point  of  view  of 
military  ophthalmic   surgery  is   the   tolerance   of  the 


88G  FRACTURES  OF  THE  ORBIT 

eye  towards  a  dislocated  lens  ;  even  in  cases  when  the 
luxation  has  been  complete  we  have  generally  found 
that  it  leads  to  no  further  damage.  This  was  so  in 
the  two  cases  of  subluxation  we  saw  amongst  cases  of 
fracture  of  the  orbit. 

The  first  case  was  one  of  fracture  of  the  left  frontal 
bone  and  the  vault  of  the  orbit,  with  manifestation  of 
cerebral  pulsation ;  in  the  left  eye  we  noted,  besides 
optic  atrophy  and  pigmented  choroido -retinitis  of  the 
macular  region,  subluxation  of  the  lens,  which  was  still 
transparent,  down  and  out.  In  the  second  case  the 
left  upper  eyelid  had  been  partially  destroyed  by  a 
piece  of  shell ;  there  was  a  breach  in  the  superior 
orbital  margin ;  the  left  eye  presented  complete  optic 
atrophy,  iridodialysis  up  and  out,  and  subluxation  of 
the  lens  down  and  out. 

(2)  Affections  of  the  Membranes  :    {a)  Uveal  Tract 

In  the  study  of  the  complications  which  involve  the 
sclerotic  we  have  no  case  to  report,  because,  when  the 
projectile  has  fractured  the  orbit  and  directly  injured 
the  eye,  the  globe  has  burst,  not  at  any  peripheral  spot, 
but  over  a  very  large  extent ;  it  has  been  destroyed. 

Limited  scleral  ruptures  do  not  apparently  occur  in 
military  surgery.  Out  of  609  cases  of  fracture  of  the 
orbit,  in  212  the  globe  has  been  destroyed  by  bursting; 
in  105  the  globe  has  been  spared  completely;  in  292 
the  deep  membranes  have  been  damaged ;  not  once 
has  the  sclerotic  been  ruptured  in  a  limited  region. 

The  fact  is  indeed  surprising,  but  one  can  only  bow 
to  the  clinical  evidence,  and  in  our  work  there  is  no 
occasion  to  speak  of  partial  ruptures  of  the  e3'eball. 

We  pass  on,  therefore,  to  traumatic  lesions  of  the 
uveal  tract. 

In  the  serious  contusions  suffered  by  the  eye  in 
fractures  of  the  orbit,  we  shall  consider  in  the  first 
place  lacerations  of  the  pupiJJaiy  margin  of  the  iris, 
and  detachment  of  the  ciliary  border;  in  the  second 
place  ruptures  of  the  choroid  and  detachment  of  this 


PRESERVATION  OF  THE  EYEBALL         887 

membrane.  We  shall  pass  in  review  successively  the 
distinctive  features  which  these  affections  have  pre- 
sented amongst  our  wounded. 

Lesions  of  the  Iris 

Laceration  of  the  pupillary  border. — It  is  known  that 
lacerations  more  or  less  visible,  though  rarely  visible 
even  to  oblique  illumination,  are  the  common  cause  of 
traumatic  mydriasis  after  contusions  of  the  eye.  It  has 
happened  to  us  to  be  able  to  identify  linear  gashes  in 
the  form  of  triangular  fissures.  One  of  our  patients, 
observed  recently,  had  this  condition  in  conjunction 
with  a  very  marked  mydriasis,  showing  two  small 
radial  fissures  between  six  and  seven  o'clock;  these 
tears  must  be  looked  for  with  the  corneal  loupe.  They 
are  \dsible  under  the  great  magnification  given  by  this 
instrument  when  the  most  careful  examination  with 
an  ordinary  lens  fails  to  detect  them. 

We  are  concerned,  as  we  said  above,  with  a  traumatic 
paralysis  directly  affecting  the  muscle,  and  one  in 
which  there  is  no  lesion  of  the  nervous  system.  It  is 
probable  that  these  lesions  of  the  sphincter  happen 
when  the  contusion  of  the  iris  takes  place  through  a 
cornea  struck  perpendicularly  to  its  basal  plane ;  the 
muscular  fibres  of  the  iris  are  themselves  compressed, 
crushed  between  the  cornea  and  the  lens,  which  resists 
only  so  far  as  it  is  supported  by  the  hyaloid  fossa. 
In  our  cases  it  has  been  impossible  to  discover  the 
direction  in  which  the  force  acted  most  strongly. 

Dialysis  of  the  iris. — There  are  several  theories  to 
explain  iridodialysis. 

According  to  Schmidt-Rimpler,  traumatic  irido- 
dialysis is  due  to  depression  of  the  sclerotic  by  the 
object  which  strikes  the  blow.  The  insertion  of  the 
iris  suffers  an  amount  of  traction  which  is  aU  the 
greater  because  the  injury  produces  at  the  same  time 
contraction  of  the  pupil,  as  was  shown  by  Berlin. 
The  iris  becomes  torn  away  close  to  its  attachment. 

FOrstee,    relying    upon    experimental    researches, 


883  FRACTURES  OF  THE  ORBIT 

points  out  that  the  aqueous  humour  is  driven  back 
towards  the  centre  of  the  eye.  The  iris  is  closely 
applied  tp  the  lens,  thus  closing  the  communication 
between  the  anterior  chamber  and  the  posterior 
chamber ;  the  pressure  stretches  the  iris  from  before 
backwards  and  ends  by  causing  it  to  give  way  in  the 
part  where  it  is  not  supported  by  the  lens,  i.  e.,  towards 
the  periphery. 

Sattler  admits  the  simultaneous  action  of  the 
depression  of  the  sclerotic  and  the  forcing  back  of  the 
aqueous  humour. 

Ballaban,  however,  points  out  that,  the  globe  being 
full  of  fluid,  there  can  be  no  marked  difference  of 
pressure  between  the  aqueous  humour  and  the  vitreous. 
The  iris  cannot  therefore  be  driven  back  against  the 
lens.  According  to  this  writer  the  sclerotic  is  de- 
pressed at  the  same  time  as  the  pupil  contracts ;  the 
wall  of  the  globe,  which  is  very  elastic,  then  recoils 
upon  itself,  overpassing  the  limits  of  its  initial  posi- 
tion. The  iris  cannot  follow  it  and  is  torn  at  its 
base,  which  is  the  least  resistant  portion  and  the  point 
of  maximum  traction. 

It  is  essential,  therefore,  that  the  blow  which  strikes 
the  eye  should  be  sudden,  indeed  instantaneous,  and 
that  it  should  attack  the  sclero -corneal  margin.  The 
youth  of  the  patients  is  a  favourable  condition, 
because  the  sclerotic  is  still  very  elastic  in  young 
subjects. 

The  most  probable  of  these  theories  appears  to  us 
to  be  that  which  explains  the  detachment  of  the  iris 
by  compression  of  the  aqueous  humour,  driven  back 
into  the  angle  of  filtration.  It  is  possible  that  this 
may  be  the  mechanism  by  which  separation  of  the 
uveal  tract  from  the  sclerotic  is  produced ;  but  it  is 
difficult  to  suppose  that  the  pathogenic  mechanism 
should  always  be  essentially  the  same. 

We  have  not  observed  iridodialysis  as  a  complica- 
tion of  fractures  of  the  orbit,  but  we  think  we  ought 
to  report  here  a  case  of  this  lesion  in  a  subject  who 
liad    a   double  dialysis  of   the  iris   after  having   been 


PRESERVATION  OF  THE  EYEBALL         889 

violently  thrown  down  by  a  shell -explosion  and  struck 
on  both  eyes  by  fragments  which  injured  the  centres 
of  both  cornese  (Fig.  37).  It  seems,  in  fact,  in  this 
case,  that  the  anterior  chamber  had  been  flattened 
out  by  the  shock,  and  that  the  cornea  had  been  made 
to  touch  the  lens,  driving  the  aqueous  humour  into 
the  spaces  of  Fontana.  The  space  of  the  iridic  angle 
had  been  over-distended,  and  the  iris  became  detached 
from  its  base  by  the  excess  of  aqueous  humour  whicli 
accumulated  in  the  angle.  The  detachment  of  the 
iris  took  place  all  the  more  readily  because  the  iris  is 
not  supported  by  the  lens  at  the  site  of  its  attach- 
ment to  the  ciliary  body.  In  short,  Forster's  theory 
seems  to  us  to  give  the  best  explanation  of  the  case 
represented  by  Fig.  37. 

Injuries  of  the  iris,  laceration  of  the  sphincter  or 
dialysis,  may  be  accompanied  by  haemorrhages  and 
inflammatory  complications.  Hsemorrhage  explains 
itself  in  dialysis,  because  the  vascular  plexus  at  the 
base  of  the  iris  may  be  ruptured  and  bleed  profusely. 
We  have .  not  seen  these  haemorrhages  in  our  cases, 
because  the  patients  have  usually  arrived  at  the  base 
several  weeks  after  the  infliction  of  their  injuries, 
so  that  the  effusion  of  blood  has  had  time  to  become 
absorbed.  Lacerations  in  the  region  of  the  sphincter 
do  not  bleed ;  there  is  only  extravasation  of  a  few 
red  corpuscles  in  the  muscular  tissue  of  the  sphincter 
iridis. 

We  have  not  gone  into  the  inflammatory  complica- 
tions, further ;  doubtless,  after  such  traumatism,  the 
blood,  which  is  laden  with  all  sorts  of  toxins,  may 
deposit  them  in  the  lacerated  tissues,  and  thus  pro- 
duce inflammation- of  endogenous  origin;  so  that  tliis 
inflammation  may  result  from  chemically  irritating 
toxins  or  from  microbes  directly  deposited  in  the 
wound  by  the  circulation. 

Contrary  to  certain  ophthalmologists,  we  tinnly 
believe  in  infections  of  internal  origin,  but  we  have 
not  met  with  them  in  our  patients. 

We  explain  this  fact  by  the  age  of  tlie  soldiers,  who 


890 


FRACTURES  OF  THE  ORBIT 


are  as  a  rule  healthy  subjects.  It  is  worn-out  subjects 
who  are  liable  to  inflammations  of  internal  origin, 
especially  old  people  with  anterio -sclerosis.  The 
old  folk  we  operate  on  for  cataract,  cardiacs,  with 
hyper-tension,  will  get  iritis  in  spite  of  perfect  asepsis, 
even  with  an  operation  with  the  conjunctival  flap, 
because  they  resist  so  badly  the  poisons  with  which 
their  aged  organisms  are  laden.  Soldiers,  habitually 
very  strong,   have   supple  vessels   and  tissues   which 


Fig.  37. 

protect  themselves  well ;  hence  injury  of  the  iris  is 
not  complicated  by  inflammatory  manifestations. 

After  traumatic  lacerations  of  the  sphincter  and 
dialysis  of  the  iris  we  must  here  notice  cases  of 
inversion  of  the  iris. 

This  accident  happens  when,  as  a  result  of  injury, 
the  intra-ocular  pressure  in  the  anterior  chamber  is 
very  suddenly  raised  :  the  sphincter  of  the  iris  is  then 
thrust  back  into  the  triangular  space  which  separates 
the  membrane  of  the  iris  from  the  lens ;  the  pupillary 
margin  turns  backwards  on  itself,  and  the  whole 
breadth  of  the  membrane  of  the  iris  follows  the 
inversion  of  its  margin ;   the  result  is  that  the  entire 


PRESERVATION  OF  THE  EYEBALL        891 

iris  becomes  finally  flattened  against  the  ciliary  body ; 
a  true  luxation  of  the  pupil  is  thus  produced. 
We  have  not  seen  any  cases  of  this  nature. 


Lesions  of  the  Choroid 

Choroidal  lesions  present  for  examination  :  (1)  Rup- 
tures of  the  choroid;  (2)  Haemorrhages  and  detach- 
ment of  the  membrane. 

These  various  disorders  are  met  with  either  when 
the  eye  has  been,  struck  directly,  or  when  a  concussion 
in  the  vicinity  has  shaken  the  organ 
with  sufficient  violence  to  rupture 
one  of  its  membranes. 

(1)  Choroidal  Ruptures — 
These  may  be  produced  directly  by 
traumatism  implicating  the  eyeball 
itself,  or  may  be  the  result  of  in- 
direct lesions  by  concussion. 

We  shall  now  study  the  first 
variety. 

{A )  DirecUchoroidal  ruptures  from 
a  blow  upon  the  eye. — There  are 
many  theories  io  explain  these. 

(1)  The  theory  of  direct  pressure 
(Ammon),  applicable  to  lacerations 
of  the  anterior  region  of  the  choroid, 
and,  exceptionally,  to  some  lacera- 
tions at  the  posterior  pole. 

(2)  The  theory  of  contre-coup  (Knapp,  Berlin, 
Seidlitz),  in  which  the  mechanism  of  certain  fractures 
of  the  skull  is  invoked. 

(3)  Becker  is  of  opinion  that  ruptures  of  the 
choroid  at  the  posterior  pole  are  due  to  the  concentric 
pressure  or  traction  of  the  optic  nerve,  exerted  at  the 
moment  of  traumatism  upon  the  posterior  pole  of  the 
globe. 

(4)  Fage  believes  that  at  the  moment  of  a  con- 
tusion the  eyeball  finds  itself  between  two  resistances, 
the  orbital  wall  on  one  side  and  the  insertion  of  the 


Fig.  38. — Equator  of 
depression  (Arlt). 


892 


FRACTURES  OF  THE  ORBIT 


Fig,  39.— Traumatism  affecting  the  lower 
part  of  the  globe.  Rupture  at  R,  in 
the  thinned  intercalary  space. 


optic  nerve  on  the  other;  between  these  two,  the 
choroid,  stretched,  and  only  slightly  extensible  by 
reason  of  the  vessels  which  bind  it  to  the  sclerotic, 

is  torn  in  a  direc- 
tion perpendicular 
to  that  of  the 
traction. 

(5)  Saemisch 
thinks  that  the  cho- 
roid tears  at  the 
point  where  it  is 
most  firmly  fixed, 
either  behind  in  the 

/     '^ITT^TT^^W^  region  of  the  disc, 

^^       ^^^y^^JI''  or  in  front  near  the 

ora  serrata. 

(6)  De  Wecker 
ascribes  great  im- 
portance to  the 
sudden  contraction 
of  the  muscles  of  the 
eye  at  the  moment 
of  injury  ;  he  thinks 
that  this  contrac- 
tion deforms  the 
globe  and  contri- 
butes to  the  cho- 
roidal rupture. 
;  Arlt  defends  the 
theory  which  he  has 
brought  forward  to 
explain  ruptures  of 
the  sclerotic.  When 
a  force  is  applied  to 
the  globe,  an  equa- 
tor   of     depression 

perpendicular  to  the  direction  of  this  force  is  estab- 
lished (Fig.  38),  and  it  is  upon  this  equator  that  the 
rupture  occurs. 

We  have  amplified  this  theory  of  Arlt  in  an  essay 


Fig.  40. — Traumatism  affecting  the  upper 
part  of  the  globe.  Rupture  at  R,  at 
the  site  of  the  intercalary  space,  the 
thinnest  portion  of  the  ocular  wall. 


PRESERVATION  OF  THE  EYEBALL         89;j 

on  ruptures  of  the  sclerotic  {Bulletin  medical,  1905, 
p.  201),  by  demonstrating  that  scleral  ruptures  are 
always  produced  at  the  thinnest  portion  of  the  wall 
of  the  eye — i.  e.,  between  the  insertion  of  the  recti 
muscles  and  the  cornea,  because  in  the  usual  ocular 
injuries,  whether  the  eye  is  struck  from  below  (Fig.  39) 
or  from  above  (Fig.  40),  the  equator  of  depression 
always  passes  through  this  thinned  portion. 

These  theories  retain  their  full  value  so  far  as  rup- 
tures of  the  choroid  by  direct  shock  are  concerned ; 
the  uveal  membrane  is  submitted  to  the  same  con- 
ditions   as    the    fibrous    coat    and    should     therefore 


rupture  on  a  line  passing  through  the  equator  of 
depression. 

We  have  had  occasion  to  demonstrate  the  truth  of 
this  explanation  in  a  case  in  which  a  young  woman, 
looking  at  a  display  of  fireworks,  received  the  falling 
stick  of  a  rocket  in  the  eye,  exactly  in  the  position 
shown  by  Fig.  41 ;  it  was  falling  from  a  great  height 
and  consequently  with  much  force. 

The  lesion  produced  in  the  eye  is  represented  in 
Fig.  42,  and  in  this  case  the  explanation  of  the 
choroidal  rupture  appears  to  us  to  be  as  follows  : — 

The  rocket -stick,  falling  with  violence  upon  the 
wounded  eye,  struck  it  with  great  force  in  the  direc- 
tion of  the  arrow,  at  the  point  A  (Fig.  41);  there 
resulted    an    equator    of    depression,  at    the    site    of 


894 


FRACTURES  OF  THE  ORBIT 


which  the  sclerotic  and  the  choroid  were  strongly 
stretched,  and  the  rupture  occurred  from  a  to  b  ; 
this  line  of  rupture  corresponds  closely  to  the  region 
lacerated  in  Fig.  42.  The  choroidal  rupture  takes 
place  there  all  the  more  readily  because,  at  this  point, 
the  choroid  is  not  adherent ;  farther  back,  towards 
the  disc,  it  adheres  to  the  sclerotic;  farther  forwards 
it  is  attached  to  the  fibrous  coat  of  the  eye  by  the 
vasa  vorticosa.     On  the  other  hand,  in  the  lacerated 

region,  from  a  to  6, 
it  glides  easily  over 
the  scleral  wall  and 
tears  when  the 
stretching  becomes 
too  great. 

If  the  sclerotic 
of  this  patient  had 
ruptured  it  would 
have  yielded  at  R, 
because  there  the 
equator  of  depres- 
sion meets  the  zone 
of  least  resistance 
of  the  sclerotic,  as 
I  laid  down  in  a 
paper  published  in 
the  Bulletin 
medical  (1903). 
Rupture  of  the  sclerotic,  between  the  cornea  and  the 
insertion  of  the  muscles,  is  explained  by  the  fact  that 
here  the  equator  of  depression  meets  the  thinnest  part 
of  the  wall  of  the  eye. 

In  the  same  manner,  when  the  sclerotic  resists  and 
the  choroid  is  torn,  the  latter  gives  way  at  the  pos- 
terior part  of  the  equator  of  depression,  at  a,  h,  for 
example,  because  it  is  there  that  it  is  the  least  firmly 
fixed  and  least  attached  to  the  scleral  envelope. 

It  is  therefore  the  theory  of  the  equator  of  depres- 
sion which  should  be  applied  when  the  eye  suffers 
contusion.     Far  from   us   be   the  thought   that  this 


Fig.  42. — Choroidal  rupture  following  the 
line  of  the  equator  of  depression. 


PRESERVATION  OF  THE  EYEBALL         895 

theory  will  explain  every  case,  for  we  believe  that 
there  is  great  diversity  in  the  pathogenesis  of  ruptures 
of  the  choroid ;  furthermore,  there  are  few  cases  in 
which  one  is  able  to  identify  the  exact  seat  of  the 
initial  traumatism  and  the  direction  of  the  force  which 
has  wounded  the  eye. 

Perhaps  it  is  by  this  mechanism  that  a  certain 
number  of  the  choroidal  ruptures  we  have  examined 
have  been  produced.  The  shock  of  the  projectile 
upon  the  eye  has  been  applied  to  a  point  of  the  sclerotic 
far  removed  from  the  choroidal  rupture,  which  has 
occurred  on  the  line  of  the  equator  of  depression. 
But  most  frequently  the  shock  has  produced  mischief 
at  the  actual  spot  where  the  globe  has  been  struck; 
so  that  choroidal  lesions  by  direct  shock  are  usually 
at  the  contused  point,  much  more  rarely  at  a  point 
removed  from  this  spot. 

It  will  be  convenient  here  to  make  a  distinction 
between  the  injuries  of  the  eyeball  caused  by  a  blunt 
instrument,  such  as  the  clenched  fist,  stone  thrown 
with  force,  etc.  (the  kind  of  contusion  one  meets  with 
often  enough  in  civil  life),  and  the  wounds  which 
implicate  the  eye  in  war. 

A  blow  from  the  fist  involves  the  formation  of  the 
equator  of  depression  of  Arlt,  and  the  choroidal 
laceration  occurs  far  from  the  point  struck.  A  pro- 
jectile of  war,  a  piece  of  shell,  which  strikes  the  eye 
directly,  like  a  whip,  does  not  produce  an  equator 
of  depression ;  it  destroys  the  organ,  tearing  it  to 
pieces. 

In  military  surgery  the  eye  is  only  injured,  without 
being  destroyed,  by  a  biUlet  which  grazes  it  tan- 
gentially,  or  by  a  small  fragment  of  shell  which,  with 
momentum  diminished  by  its  flight,  strikes  a  circum- 
scribed spot.  There  is  then  no  equator  of  depression, 
but  a  wound  at  the  place  contused. 

In  short,  what  happens  to  the  sclerotic  happens  to 
the  choroid,  in  our  cases.  There  are  not,  or  at  any 
rate  very  rarely,  ruptures  influenced  by  the  equator 
of  depression,  because  all  projectiles,  striking  the  eye 


89G  FRACTURES  OF  THE  ORBIT 

violently,  perpendicular  to  it,  lead  to  its  destruction, 
pure  and  simple. 

We  have  recalled  Arlt's  theory  and  demonstrated 
its  value,  but  in  reality  it  applies  very  little  to  military 
surgery.  In  thirty  months'  observation  in  a  military 
hospital,  well  supplied  witli  patients,  we  have  not 
seen  a  single  case  of  scleral  rupture  bearing  on  this 
theory.  We  are  less  emphatic  concerning  choroidal 
ruptures  ;  there  may  perhaps  be  a  few  examples,  as 
in  Fig.  44,  which  represents  a  longitudinal  rupture, 
in  a  patient  who  had  been  struck  by  a  piece  of  shell, 
exactly  on  the  level  of  the  left  frontal  sinus,  the  crushed 
inferior  wall  of  which  must  have  bruised  the  eyeball 
directly.  It  is  possible  that  an  equator  was  produced 
there,  according  to  Arlt's  theory,  and  that  the  line 
of  retino -choroidal  rupture  formed  part  of  it.  The 
cases  in  Plate  IV,  Figs.  1,  3  and  4,  and  Plate  VI, 
Figs.  1  and  2,  call  forth  the  same  reflections,  but  we 
believe  that  ruptures  of  the  deep  membranes  rarely 
depend  on  this  mechanism ;  the  lesions  of  the  uveal 
tract  which  result  from  a  blow  on  the  eye  are  situated 
at  the  point  struck. 

The  lesion  thus  produced  is,  moreover,  serious. 
There  is  free  haemorrhage,  invading  the  vitreous — 
these  are  the  cases  which  result  in  retinitis  proliferans. 
We  have  noted  a  considerable  number  of  cases  of  this 
condition,  which  would  risk  encumbering  this  work 
needlessly  if  reported  here. 

{B)  Indirect  or  mediate  choroidal  ruptures. — The  cases 
which  I  have  now  to  bring  forward  are  intra-ocular 
disorders  consecutive  to  concussion  in  the  vicinity  of 
the  eye. 

These  cases  are  rare,  and  have  been  but  little  studied. 
But  they  are  not  the  only  ones  which  have  been 
reported  in  our  scientific  records,  and,  without  pre- 
tending to  give  here  a  complete  bibliography,  we  can 
quote  a  case  from  Von  Ammon,  which  appears  to  be 
the  first,  of  rupture  of  the  choroid  by  concussion ; 
Carl  Genth,  at  Pagenstecher's  Ophthalmological 
Institute,  observed  three  cases  in  which  lesions  of  the 


PRESERVATION   OF   THE  EYEBALL  807 

ocular  membranes  occurred,  without  the  eye  having 
been  touched,  following  injuries  to  the  bones  of  the 
orbit. 

Joy  Jeffries,  of  Boston,  reports  a  case  of  rupture 
of  the  choroid  without  direct  lesion  of  the  eye,  which 
resembles  in  every  respect  the  cases  which  the  reader 
will  find  below. 

A  young  man,  aged  fifteen,  was  about  to  enter  a 
bam;  he  struck  his  forehead  against  a  beam,  and  the 
shock  stunned  him.  He  was  not,  it  seemed,  very 
seriously  injured,  the  effect  of  the  blow  having  imme- 
diately passed  off ;  but  three  days  later  he  saw  black 
patches  before  the  left  eye.  On  examination,  two 
crescent-shaped  [acerations  of  the  choroid  were  found. 

Two  similar  cases  are  reported  in  much  detail  by 
Mannhardt. 

The  first  concerns  a  man  of  thirty-five  who  was 
carrying,  with  a  comrade,  a  heavy  load,  which  the 
latter  dropped  suddenly.  A  laceration  of  the  choroid 
was  produced,  which  the  author  does  not  hesitate  to 
attribute  to  concussion. 

In  the  second  case  the  rupture  of  the  choroid  was 
due  to  a  fall  from  a  height  of  forty  feet. 

Parisotti  and  Haas  have  published  similar  cases. 
The  latter  author's  case  was  a  child  of  nine  years, 
struck  on  the  head  in  the  neighbourhood  of  the  right 
eye  by  a  violent  blow  with  a  stick.  He  showed, 
after  absorption,  haemorrhages  into  the  vitreous,  and 
crescent-shaped  laceration  of  the  choroid  and  retina 
immediately  above  the  disc. 

Choroidal  injuries  by  vibratory  shock  are  therefore 
well  known ;  and  Norman  Hansen  is  certainly  in 
error  when  he  denies  their  possibility,  as  he  does  in 
a  work  entitled,  "  Under  what  conditions  can  a 
choroidal  laceration  be  produced  in  gunshot  wounds 
of  the  temporal  region  ?  "  This  author  believes,  from 
the  study  of  eight  cases,  that  choroidal  rupture  takes 
place  only  when  the  projectile  strikes  the  eyeball 
directly,  or  when  distension  of  the  globe  is  produced, 
as  in  the  case  of  violent  laceration  of  the  optic  nerve. 


898  FRACTURES  OF  THE  ORBIT 

Norman  Hansen  is  right  so  far  as  injuries  of  the 
optic  nerve  are  concerned.  It  is  certain  that  a  bullet, 
striking  the  nerve  behind  the  eye,  stretches  the  ocular 
membranes  in  a  direct  manner;  and  when  the  pro- 
jectile has  traversed  the  orbit  behind  the  eyeball  the 
traumatism  is  in  some  way  directly  transmitted  to 
the  intra-orbital  membranes  by  the  stretched  optic 
nerve.  We  report  several  very  clear  cases,  but 
Norman  Hansen  is  in  error  when  he  denies  the 
possibility  of  choroidal  ruptures  from  lesions  in  the 
neighbourhood,  where  none  of  the  organs  contained  in 
the  orbit  has  been  directly  implicated. 

De  Wecker  was  better  inspired  when  he  wrote  : 
"  All  those  who,  during  the  sad  war  of  1870,  had 
occasion  to  examine  many  injuries  to  the  head,  sub- 
mitting the  wounded  to  ophthalmoscopic  examinations, 
have  been  able  to  convince  themselves  that  ruptures 
of  the  choroid  constantly  accompany,  in  some  way  or 
other,  all  the  concussions  and  violent  shocks  to  the 
bony  framework  of  the  upper  portion  of  the  face." 

The  possibility  of  the  lesions  which  we  are  about 
to  study,  therefore,  is  generally  accepted  by  ophthalmic 
surgeons,  but  we  do  not  think  that,  up  to  now,  these 
affections  have  been  reported  with  any  details,  and 
it  is  for  this  reason  that  we  wish  to  publish  the  cases 
which  follow.  They  have  already  been  the  subject  of 
a  paper  communicated  to  1 'Academic  de  Medicine, 
May  15,  1915.  Before  this  date  Yarr,  LiiGUES, 
Charles  Lee,  Harman,  quoted  by  Prof.  Baudry 
{Traumatisms  de  Voeil  au  point  de  vue  medico-legal, 
p.  168),  had  reported  cases  o°f  loss  of  vision  following 
shell -explosion  by  indirect  concussion,  but,  no  more 
than  the  authors  cited  above,  had  they  described  the 
lesions  in  the  fundus  of  the  eye.  Our  publication  of 
May  15,  1915  is  the  first  in  which  the  macular  lesions 
and  the  choroidal  lacerations  have  been  studied  and 
represented  in  detail.  A  little  later,  our  colleague 
Terrien,  in  the  Archives  dVphtalmologie  appearing  at 
the  end  of  June,  1915,  quoted  cases  which  may  in 
every  respect  be  placed  beside  ours,  and  which  entirely 


PRESERVATION  OF  THE  EYEBALL        899 

corroborate  our  conclusions  relative  to  macular  lesions 
by  concussion.  We  would  reproduce  them  here,  were 
it  not  that  the  limits  of  this  book,  in  which  we  are  not 
publishing  the  fourth  part  of  our  own  observations, 
forbade  it.  We  may  say  the  same  of  Dantrelle's 
cases  {Archives  d'Ophtalmologie,  Sep.-Oct.  1915),  who 
has  published  representations  of  the  fundus  of  the  eye, 
analogous  to  ours,  some  months  after  us,  and  who, 
perhaps,  has  not  adequately  noted  that  our  article 
contained  cases,  similar  to  his,  of  macular  lesions  by 
concussion,  following  violent  injury  to  the  bones  of 
the  face. 

Similar  cases,  moreover,  are  being  quite  generally 
observed;  at  the  "Centre  secondaire  d 'Angers  " 
GiNESTOUS  has  been  able  to  collect  a  large  number 
{Gazette  hebdomadaire  de  Bordeaux,  Nov.  1916). 

All  the  personal  observations  which  are  now  about  to 
be  placed  before  the  reader  would  have  found  a  natural 
place  in  groups  II,  III,  and  IV  (p  SlSet  seq.)  of  cases 
reported  to  demonstrate  the  truth  of  the  laws  which 
govern  lesions  of  the  eye  in  injuries  implicating  the 
orbital  region.  We  thought  it  better  to  record  them 
here,  because  we  shall  be  able  to  describe  in  detail  the 
lesions  of  the  choroid  and  retina  with  their  manifold 
ophthalmoscopic  varieties. 

The  cases  reported  above  (p.  814  et  seq.),  in  five 
groups,  are  merely  examples  ;  we  have  only  grouped  a 
few  in  each  category  ;  we  might  have  doubled  or  tripled 
the  number,  for  on  this  subject  we  have  abundance  of 
evidence. 

The  same  applies  to  the  cases  which  follow ;  they  are 
chosen  from  amongst  many  others,  similar,  and  of 
equal  clinical  value. 

Wound  of  right  temporal  fossa ;    detachment  of  retina,  R.  E. 

(Case  30.) 

C,  wounded  Oct.  29  by  a  rifle  bullet  which  penetrated 
above  the  right  eyebrow  (at  the  level  of  the  external  third), 
traced  a  deep  lurrow  in  the  temporal  muscle  and  emerged  a 
finger's  breadth  above  the  right  tragus. 


900 


FRACTURES  OF  THE  ORBIT 


The  external  orbital  margin  is  fractured,  as  well  as  the 
malar  process  of  the  maxilla ;  the  latter  fracture  causes 
deformity  of  the  floor  of  the  orbit  and  the  globe  is  slightl}* 
de\^ated  downwards.  Beyond  this  the  eye  presents  no  trace 
of  injury. 

Examination  shows  that  the  right  eye  has  only  quantita- 
tive vision.     There  is  a  large  detachment  of  the  retina. 

The  left  eye,  normal,  has  acuity  1  with  4-  0  75  D  sph. 

Perforating  wound  of  the  right  temporal  fossa  ;    rupture  of 
choroid,  R.  E.    (Case  31.) 

L.,  wounded  at  Ypres,  Nov.  5.  A  bullet  penetrated 
near  the  outer  end  of  the  right  ej^ebrow,  close  to  the  orbital 


Fig.  43. 


margin,  which,  however,  it  did  not  injure ;  it  emerged  from 
the  temporal  fossa  after  a  perfectly  horizontal  course  two 
fingers  in  breadth  in  the  cellular  tissue ;  radiography  showed 
no  bony  lesion. 

The  right  eye  presents  outwardly  no  trace  of  injury,  but 
has  only  quantitative  vision.  Stud}^  of  the  \isual  field 
shows  that  central  vision  is  abolished,  and  the  ophthalmo- 
scopic examination  reveals  grave  lesions.  The  whole  of 
the  posterior  pole  is  covered  with  abundant  pigmentation, 
through  which  it  is  possible  to  see,  near  the  macula,  a  severe 
laceration  of  the  choroid  in  the  form  of  a  crescent,  the 
convesity  of  which  is  turned  towards  the  disc.  The  left 
eye  is  normal  (Plate  V,  Fig.  1). 

Cantusions  of  the  left  orbital  margin  ;  rupture  of  choroid,  L.  E. 

(Case  32.) 

P.,  wounded  Oct.  6,  near  Arras.     He  was  struck  by  a 


PRESERVATION  OF   THE  EYEBALL         901 

la  ge  piece  of  shell,  which  injured  at  the  same  time  the  infra- 
orbital region  and  the  bridge  of  the  nose,  producing  in  this 
j^egion  contused  wounds,  but  leaving  quite  intact  the  eye- 
lids and  the  globe  itself. 

R.  E,  has  an  acuity  of  9/10  with  correction;  the  visual 
field  is  normal ;   no  lesion  can  be  found. 

L.  E.,  acuity  =  1/100,  not  improved  by  glasses  ;  with  the 
ophthalmoscope  numerous  floating  bodies  in  the  vitreous 
and  serious  lesions  of  the  membranes  are  seen.  A  large 
laceration  of  the  choroid,  of  irregular  form,  occupies  the 
posterior  pole  quite  close  to  the  macular  region. 

It  is  surrounded  by  an  inflammatory  zone,  characterised 
by  dense  black  pigmentation. 

A  large  detachment  of  the  retina  is  situated  below.  This 
latter  lesion  disappeared  after  some  weeks  of  treatment, 
but  vision  was  not  improved. 

The  lesions  of  this  eye  are  manifestly  and  essentially 
choroidal  lesions.  Over  the  portion  of  the  rupture  nearest 
to  the  disc  five  retinal  vessels  may  be  seen  passing  over  the 
tear  in  the  choroid ;  in  the  same  way,  two  vessels  are  very 
evident  crossing  the  choroidal  rupture  perpendicularly  in  a 
part  furthest  from  the  papilla.  Another  vessel  seems  to 
have  disappeared,  but  in  reality  it  has  been  covered  by 
proliferating  retinitis  (Plate  V,  Fig.  2). 

Traumatism  of  the  malar  region  ;    optic  neuritis  ;    rupture  of 
the  choroid,  R.  E.    (Case  33.) 

R.  was  struck  by  a  bullet,  Sep.  6.  The  projectile 
penetrated  one  centimetre  behind  the  right  angle  of  the 
mandible,  and  emerged  by  a  large  wound  near  the  malar 
process  of  the  maxilla  of  the  same  side.  The  maxillary 
antrum  had  been  widely  laid  open,  and  the  man  has  had  a 
fistula,  healed  when  he  came  under  our  observation.  He 
had  lost  the  sight  of  the  right  eye  since  the  injury. 

R.  E.,  with  -2D  sph.,  V  =  0. 

The  disc  has  the  classic  aspect  of  post-neuritic  atrophy-. 
Moreover,  the  macular  region  is  covered  by  abundant 
pigmentation  which  doubtless  hides  the  lesions  of  the 
choroid,  probably  small  lacerations  followed  by  haemorrhage 
(Plate  V,  Fig.  3).  The  left  eye,  equally  myopic,  has  the 
acuity  1  with  —2D  sph.,  and  presents  no  lesion. 


902  FRACTURES  OF   THE  ORBIT 

Perforating  wound  of  the  right  orbit ;    rupture  of  the  choroid, 
R.  E.     (Case  34.) 

S.  was  wounded  at  Luneville,  Aug.  22.  A  piece  of  shell 
penetrated  the  right  temporal  region,  a  finger's  breadth  be- 
hind the  extremity  of  the  eyebrow ;  it  traversed  the  orbit 
from  above  downwards  and  from  behind  forwards,  coming 
to  rest  in  the  vault  of  the  palate. 

Careful  study  of  the  course  of  the  missile  showed  that  it 
had  passed  outside  the  optic  nerve  and  behind  the  eyeball, 
and  it  seems  to  us  certain  that  the  globe  had  not  been 
touched,  for  two  reasons :  (1)  because  the  rectilinear 
course  of  the  projectile  traced  from  the  aperture  of  entry  to 
the  orifice  of  exit  passes  behind  the  eye ;  (2)  because  such 
a  projectile,  capable  of  penetrating  several  bony  chambers, 
would  certainly  have  ruptured  the  eye  if  it  had  struck  it ; 
further,  the  optic  nerve  itself  has  been  spared,  for  lacerations 
of  the  optic  nerve,  of  which  we  have  seen  several  cases,  are 
accompanied  by  much  more  definitely  marked  damage  to 
the  deep  membranes. 

The  left  eye  is  quite  normal.  The  right  eye  (the  affected 
side)  has  an  acuity  of  no  more  than  1/200,  not  improved  by 
glasses.  The  ophthalmoscope  shows,  near  the  macula,  two 
lacerations  of  the  choroid,  parallel  and  fusiform.  The  retina 
is  intact,  as  witnessed  by  the  fine  retinal  vessels  which  pass 
over  the  choroidal  rupture  (Plate  V,  Fig.  4). 

Perforating  bullet-wound  traversing  the  malar  bones  and  the 
nasal  fossae ;    Ghoroido-retinitis,  L.  E.    (Case  35.) 

P.  was  wounded  Sep.  15,  1914.  A  bullet  entered  under 
the  left  eye  and  came  out  under  the  right  eye  after  having 
traversed  the  nasal  fossse. 

Case  examined  Nov.  10.  The  patient  then  presented 
no  lesions  of  the  anterior  segments ;  the  cutaneous  wounds 
have  been  healed  for  a  long  time,  conjunctivae  and  sclerotics 
are  intact,  no  ophthalmoscopic  lesions.  Visual  acuity, 
however,  on  the  right  is  1/10,  not  improved  by  glasses ;  on 
the  left  it  equals  0. 

The  patient  has  been  regarded  as  a  malingerer  and  exam- 
ined in  consequence,  but  it  is  impossible  to  prove  him  in 
fault.  We  confined  ourselves  to  observing  him.  A  fort- 
night later,  in  the  lower  portion  of  the  retina  of  the  left 
eye,  pathological  pigmentation  appeared. 


PRESERVATION  OF  THE  EYEBALL        903 

This  pigmentation  is  probably  the  consequence  of  small 
choroidal  haemorrhages,  themselves  coinciding  with  slight 
lacerations  disseminated  about  the  uveal  tract. 

Traumatism  of  the  malar  region  ;    rupture  of  the  choroid  ; 
retinitis  proliferans,  L.  E.    (Case  36.) 

Q.,  wounded  Oct.  4,  was  made  prisoner  and  returned  from 
captivity.  He  had  been  struck  on  the  face  by  nuinerous 
shell  fragments  :  one  had  severed  the  right  eye,  which  is 
no  more  than  a  stump ;  another  fragment  penetrated  at  the 
level  of  the  left  malar  bone,  which  it  had  fractured.  The 
left  eye  presents  no  outward  trace  of  injury;  it  has  not 
been  touched  by  the  fragment  of  shell.  Nevertheless,  it 
bears  evidence  of  great  damage.  The  disc  is  only  recog- 
nisable by  the  presence  of  two  veins,  partly  covered  by 
traces  of  proliferating  retinitis.  Below  and  to  the  outer 
side  is  seen  a  large  laceration  of  the  choroid,  with  pigmenta- 
tion on  its  margins.  It  is  a  large,  pearly  white  plaque,  over 
whiclv  pass  the  retinal  vessels.     Blindness  is  complete. 

To  these  cases  we  will  add  the  following,  which  is  a 
very  good  example  of  the  lesions  which  projectiles 
producing  strong  concussion  in  the  bony  mass  of  the 
face  can  bring  about  in  the  fundus  of  the  eye. 


Traumatism  of  the  bones  of  the  face  ;   rupture  of  the  choroid, 
L.  E.     (Case  37.) 

H.  was  wounded  Aug.  22,  1914.  The  bullet  penetrated 
behind  the  ascending  ramus  of  the  malar  bone,  two  centi- 
metres below  the  floor  of  the  right  orbit.  It  crossed  the 
right  antrum,  the  palatine  vault,  and  came  out  on  the  left 
cheek,  a  little  above  the  angle  of  the  mandible.  The  patient 
thinks  that  the  shot  was  fired  from  about  400  metres. 

The  loss  of  vision  of  the  left  eye  was  almost  immediate ;  at 
the  same  time  severe  conjunctival  ecchymosis  appeared, 
which  remained  for  a  long  time. 

Examination  by  the  ophthalmoscope  shows  a  large 
laceration  of  the  choroid,  situated  in  the  macular  region 
(Plate  VI,  Fig.  3).  The  left  eye  has  also  lost  central  vision. 
The  right  eye  is  normal ;  its  visual  acuity  equals  unity. 


90  4  FRACTURED  OF   THE  ORBIT 

With  these  derangements,  due  to  the  concussion  of 
soft  parts  in  relation  with  the  ej^e,  might  be  compared 
a  very  curious  case  of  the  effects  of  airconcussion  upon 
a  myope. 

Progressive  myopia  ;    macular  choroido-reunitis,  R.  E. 

(Case  38.) 

Aug.  25,  C.  was  thrown  into  the  air  by  the  explosion  of 
a  shell  which  burst  alongside  him.  He  remained  about  ten 
minutes  unconscious.  When  he  came  to  himself  he  dis- 
covered that  he  had  not  a  scratch,  and  went  on  fighting. 
Next  day  there  was  some  pain  in  the  right  eye;  however,  he 
continued  to  fight,  firing  as  before.  Sep.  25,  he  was  slightly 
wounded  in  the  right  arm,  and  sent  to  Bordeaux.  There  he 
stated  that  the  visual  acuity  of  the  right  eye  was  rapidly 
diminishing. 

It  should  be  noted  that  C.  was  an  engraver  on  glass  and 
that  he  carried  on  his  calling  without  needing  to  wear  glasses  ; 
he  had  done  his  military  service,  having  left  the  regi- 
ment with  the  rank  of  corporal ;  he  was  a  very  good  shot, 
and  only  used  the  right  eye. 

R.  E.,  with  -  13  D  sph.  3  -  2  D  cyl.,  axis  30° 
V  =  quantitative,  not  improved  by  glasses.  The  anterior 
segment  and  the  transparent  media  are  normal.  On 
ophthalmoscopic  examination  a  myopic  posterior  staphy- 
loma and  a  macular  choroido-retinitis,  with  large  uveal 
lacerations,  are  revealed. 

L.  E.  is  sHghtly  hypermetropic  ;  with  -f  0  50  D  sph.,  V  == 
4/10.  This  eye  presents  a  slight  commencing  staphyloma, 
quite  like  a  typical  crescent-shaped  myopic  staphyloma 
(Plate  VI,  Fig.  4). 

Jan.  20,  his  condition  was  stationary.  It  was  impos- 
sible to  come  to  a  decision  on  his  case ;  so  he  was  sent  on 
convalescent  leave  in  order  that,  in, a  few  months,  one 
might  estimate  definitively  the  condition  of  the  eye,  and 
come  to  a  conclusion  about  the  case.  It  did  not  appear  to 
me  to  be  probable  that  the  myopia  was  entirely  consecutive 
to  the  concussion  of  the  deep  membranes,  but  it  is  certain 
that  the  macular  and  peri-macular  choroidal  lacerations, 
which  have  caused  the  suppression  of  vision  of  this  myopic 
eye,  have  been  the  result  of  traumatism  by  displacement 
of  air.     It  might  be  equally  considered  probable  that  the 


PRESERVATION  OF  THE  EYEBALL         905 

fundus  of  the  eye  has  lost  some  of  its  resisting  power  under 
the  influence  of  these  lacerations,  and  that  for  this  reason 
the  eye  is  elongated,  so  much  so  as  to  reach  the  figure  of 
thirteen  dioptres  of  myopia.  Perhaps  myopia  existed 
before  the  war,  but  it  must  have  been  very  slight,  since  C. 
was  considered  an  excellent  shot,  and,  when  shooting, 
used  only  the  right  eye. 

Such  are  the  precise  observations,  chosen  from 
amongst  many  others,  which  we  have  been  able  to 
collect ;  they  appear  to  us  to  be  worthy  to  be  placed 
on  record,  an  i  I  consider  that  they  allow  us  to  draw  up 
here,  in  the  furm  of  a  synthetic  resume,  the  four  follow- 
ing conclusions. 

1.  Projectiles,  when  they  penetrate  the  organism, 
are  capable  of  producing  at  a  distance  serious  or  irre- 
parable damage  to  nerve  centres,  to  peripheral  nerves, 
and  to  the  organs  of  special  sense  (eye,  ear,  nose). 

2.  It  is  not  necessary,  to  bring  about  this  damage, 
that  the  projectile  should  actually  strike  the  patient ; 
the  displacement  of  the  air  produced  by  the  explosion 
of  a  shell  is  sufficient  to  cause  the  same  lesions. 

3.  In  injuries  of  the  face  or  cranium  an  exhaustive 
examination  of  the  visual  apparatus  should  always  be 
made. 

4.  The  injuries  are  especially  lesions  of  the  posterior 
pole,  macular  and  peri-macular. 

Whether  the  choroid  be  implicated  alone  or  whether 
the  retina  be  lacerated  with  it,  it  is  the  macular  region 
and  its  more  or  less  immediate  surroundings  which 
suffer  more  or  less,  according  to  the  force  of  the  trau- 
matism, and  we  might  inscribe  here  this  clinical  law — 
Concussion  of  the  eye  ivitliout  direct  shock  =  macular 
and  peri-macular  lesion. 

(2)      HAEMORRHAGES      AND       DETACHMENT      OF      THE 

Choroid. — After  ruptures  of  the  choroid,  and  also  with 
them,  for  they  are  closely  connected,  haemorrhages 
of  this  membrane  must  be  mentioned.  The  type  of 
these  disorders  is  the  expulsive,  haemorrhage  (Albert 
Terson)  which  sometimes  happens  after  the  operation 


906  FRACTURES  OF  THE  ORBIT 

for  cataract.  To  a  smaller  degree  this  accident  is 
met  with  in  the  serious  contusions  of  the  eyeball.  The 
blood  is  extravasated  in  the  supra-choroidal  space  and 
the  choroid  is  lifted  up  at  the  same  time  as  the  retina. 
This  detachment  is  distinguished  from  retinal  detach- 
ment in  that  it  has  a  darker  tint  and  is  supported  by  a 
coagulum,  so  that  it  does  not  undulate  with  the  move- 
ment of  the  globe.  In  fact,  we  see  the  ophthalmoscopic 
picture  jdelded  by  certain  sarcomata  of  the  choroid ; 
the  fact  of  the  traumatic  origin  and  the  use  of  transil- 
lumination will  serve  to  establish  the  diagnosis. 

The  blood,  poured  out  at  first  in  the  supra-choroidal 
space,  soon  diffuses  into  the  anterior  layers  of  the 
choroid.  After  a  while  the  blood-clots  organise ; 
connective  tissue  cells  appear  at  the  periphery  of  the 
clot  and  soon  invade  it ;  numerous  capillaries  even  are 
formed,  which  penetrate  all  the  neighbouring  tissues, 
including  the  retina,  and  the  process  ends  in  what  we 
describe  later  under  the  name  of  proliferating  choroido- 
retinitis. 

Many  ocular  injuries,  consecutive  to  fractures  of  the 
orbit,  have  this  fate,  for  the  violent  contusion  suffered 
by  the  globe  in  such  a  case  is  very  often  accompanied 
by  haemorrhage,  with  or  without  evident  lacerations 
of  the  two  membranes,  choroid  and  retina ;  several 
examples  are  given  in  the  illustrations  published  in 
this  work,  for  we  have  had  in  our  clinic  plenty  of 
cases  to  choose  from. 

(2)  Affections  of  the  Membranes  :  (b)  Retina 

It  is  very  true,  and  Mangini  in  his  thesis  has  already 
insisted  upon  this  point,  that  pure  choroidal  lesions 
and  unmixed  retinal  lesions  are  relatively  rare,  and 
that  most  frequently  they  are  associated.  In  combina- 
tion with  a  choroidal  or  peri -macular  laceration  in  the 
form  of  the  arc  of  a  circle,  for  example,  we  may  find  a 
typical  macular  retinal  lesion,  and  one  frequently  meets 
a  laceration  affecting  at  the  same  time  both  the  choroid 
and  the  retina.     Nevertheless  the  pure  types  are  fairly 


PRESERVATION  OF  THE  EYEBALL        907 

numerous,  owing  to  the  anatomical  independence  of  the 
choroid  (including  in  this  term  the  pigmented  epithe- 
lium) and  the  retina,  properly  so-called  (the  distal 
lamina  of  the  secondary  optic  vesicle). 

According  to  our  views,  those  authors  are  quite 
wrong  who  have  refused  to  admit  the  localisation  of  the 
rupture  in  the  choroid.  Wennemann,  in  the  Encyclo- 
pedic frangaise  d'Ophtalmologie  (Vol.  VI,  p.  486),  has 
written  that  "  the  choroid  can  scarcely  be  torn  so  Jong 
as  the  sclerotic  resists  the  shock  of  the  violent  contu- 
sion, and  that  we  often  take  for  ruptures  of  the  choroid 
what  are  only  simple  folds  of  the  retina."  Clinical 
facts  invalidate  this  opinion,  and  we  are  convinced  of 
the  contrary ;  Figs.  2  and  4  in  Plate  V  are,  in  fact, 
demonstrative.  Their  value  is  increased  by  the  fact 
that  they  represent  photographs  of  oil-paintings,  made 
by  Thomer's  method  by  an  artist  of  great  talent,  who 
had  no  ophthalmoscopic  knowledge,  and  who  set  him- 
self to  paint  what  he  saw,  and  nothing  but  what  he 
saw. 

The  retinal  vessels,  which  in  these  illustrations  cross 
over  the  choroidal  laceration,  belong  to  an  intact 
retina. 

On  the  other  hand,  there  are  pure  lesions  of  the  retina 
independent  of  any  affection  of  the  choroid ;  they  are 
represented  in  Plate  I,  Figs.  1  and  2. 

From  the  anatomico -clinical  point  of  view  we  shall 
describe  three  varieties  of  retinal  lesions  :  (a)  Retinitis 
proliferans  ;  (b)  Proliferating  choroido -retinitis  ;  (c) 
Traumatic  detachment  of  the  retina. 

The  first  and  the  third  of  these  affections  are  well 
known  and  described  in  all  the  text-books  ;  we  have  only 
to  indicate  here  the  peculiarities  they  have  exhibited 
amongst  our  patients.  The  second  has  not  hitherto 
been  described. 


(a)   Retinitis  proliferans 

Proliferating  retinitis  is  often  of  traumatic  origin, 
according  to   SchiOtz  in  22  times  out  of    100,   and 


908  FRACTURES  OF  THE  ORBIT 

one  cannot  be  surprised  if,  with  the  great  majority 
of  authors,  we  ascribe  it  to  retinal  haemorrhages. 
GoLDZiEHER  has  upheld  the  view  that  proliferating 
retinitis  may  develop  without  haemorrhage,  and  that  it 
is  a  disease  sui  generis,  resulting  in  the  formation  of 
masses  of  connective  tissue  by  proliferation  of  the  fibres 
of  MuLLER.  Manz,  who  first  described  the  condition, 
ascribes  great  importance  to  effusions  of  blood,  but 
does  not  think  that  haemorrhages  are  essential  to  the 
proliferation  of  the  retinal  tissue.  It  was  Leber  who 
insisted  upon  the  important  role  played  by  extrava- 
sations of  blood  in  the  pathogeny  of  the  affection.  We 
believe  that  he  is  right ;  they  have  been  the  basis  of  all 
the  cases  of  proliferating  retinitis  we  have  seen,  and  in 
ScHioTz'  statistics,  out  of  121  cases,  these  haemorrhages 
were  only  lacking  four  times.  Besides,  it  is  sufficient 
to  inject  blood  into  the  vitreous  body  of  animals,  as 
Probsting  has  done,  to  see,  associated  with  the  haemor- 
rhage, the  proliferation  of  the  connective  tissue  of  the 
retina  ;  the  development  of  the  retina  attains  in  a  few 
weeks  three  or  four  times  the  normal  thickness  of  the 
membrane ;  three  or  four  months  after  the  injection 
the  retina  is  in  places  transformed  into  strings  of  con- 
nective tissue,  containing,  in  the  thickness  of  fibrillar 
masses,  red  corpuscles,  more  or  less  altered. 

These  anatomical  examinations,  based  on  experimen- 
tal facts,  agree  moreover  with  the  results  yielded  by 
some  examinations  of  the  human  eye,  cases  of  retinitis 
proliferans ;  the  examinations  of  Massy,  Purtscher, 
and  Verkli  have  shown  the  existence  of  a  membrane 
of  fibrillar  connective  tissues,  adhering  at  certain  points 
to  the  optic  disc  and  the  retina.  Manz,  whose  case 
was  of  four  years'  duration,  did  not  find  haemorrhagic 
debris,  probably  because  of  the  long  duration  of  the 
affection.  Denig,  Purtscher  and  Verkli  observed, 
in  the  masses  of  more  recent  formation,  numerous  traces 
of  blood  (lymphocytes,  disorganised  red  corpuscles, 
numerous  leucocytes).  The  external  layers  of  the 
retina  have  often  preserved  their  normal  structure ; 
the  internal  portions,  the  fibres  of  MtJLLER,  are  those 


PRESERVATION  OF   THE  EYEBALL         909 

which  have  proliferated.  The  pigment  epitheUum  is 
intact,  so  that  the  affection  does  not  estabhsn  artificial 
adhesions  between  the  two  layers  developed  from  the 
secondary  optic  vesicle,  i.e.,  between  the  pigmented 
epithelium  and  the  retina,  properly  so-called.  The 
result  is  that  the  fibrou,  contraction  of  the  bands  of 
connective  tissue,  of  which  we  have  just  spoken,  easily 
separates  these  two  layers,  which  are  simply  apposed 
to  one  another,  and  produces  what  we  call,  clinically, 
detachment  of  the  retina — i.e.,  separation  of  the  two 
layers  of  the  optic  vesicle. 

Retinal  detachment  is  in  consequence  frequent  in 
proliferating  retinitis. 

Such  are  the  general  data  which  apply  to  this  affec- 
tion ;  it  often  occurs  in  relapsing  spontaneous  hsomor- 
rhages  of  the  retina.  It  is  equally  common,  and  indeed 
it  should  be  looked  for,  after  the  lesions  of  the  eyeball 
which  accompany  choroidal  and  retinal  haemorrhages, 
as  well  as  effusion  of  blood  into  the  vitreous  body. 

We  have  observed  this  very  frequently,  and  we  will 
now  apply  ourselves  to  the  task  of  portraying  the 
characteristics  of  the  cases  we  have  observed. 

Symptomatology. — The  symptoms  at  the  onset  of 
proliferating  retinitis  are  those  of  haemorrhages,  and, 
as  in  the  traumatic  cases  the  affections  are  well 
marked,  we  find  usually  not  photopsise  and  scotomata, 
but  complete  loss  of  vision.  As  the  blood  becomes 
gradually  absorbed  vision  may  return,  and  sometimes 
be  even  relatively  good,  with  quite  extensive  lesions ; 
this  depends  evidently  on  the  seat  of  the  retinal  dis- 
orders visible  with  the  ophthalmoscope,  and  also  on  the 
seat  of  the  affections  which  cannot  be  seen,  for  a  very 
slight  alteration  of  the  macular  region  is  sufficient  to 
diminish  or  suppress  central  visual  acuity  in  a  subject 
whose  lesions  appear  to  be  of  slight  extent. 

Moreover,  it  is  by  no  means  rare  to  find  that  diatheses 
or  infections  with  which  the  subject  has  been  attacked 
contribute  to  complicate  the  accidents  by  pouring 
toxins  or  infectious  agents  over  the  retinal  laceration. 
The  soldiers  whom  we  have  examined,  in  general  health}' 


910  FRACTURES  OF  THE  ORBIT 

and  vigorous,  have  perhaps  been  less  exposed  to  such 
complications  than  the  generality  of  patients ;  but 
it  has  been  evident  to  us,  on  several  occasions,  that 
syphilis  has  interfered  with  the  normal  evolution  of 
the  anatomical  disorders. 

The  natural  progress  of  these  affections  leads  to  the 
organisation  of  connective  tissue,  and  for  the  same 
reason,  being  subject  to  the  general  laws  of  pathological 
anatomy,  to  contraction.  This  contraction  has  the 
great  detriment  of  dragging  on  the  retina  and  detaching 
it ;  sometimes  it  may  even  produce  a  tear  in  the  new- 
formed  membranous  veil,  thus  laying  bare  a  healthy 
portion  of  the  retina,  which  is  rendered  capable  of  dis- 
charging its  functions.  Gonin,  in  an  excellent  article 
in  the  Encyclopedie,  reports  the  history  of  a  case  in 
which  the  central  visual  acuity  came  back  to  5/10 
by  reason  of  a  laceration  occurring  in  the  macular 
region ;  the  patient  related  how  he  had  seen,  in  the 
space  of  a  very  few  days,  as  it  were  a  window  open  in 
the  centre  of  the  thick  veil  which  covered  his  eye. 

After  having  described  classic  retinitis  proliferans, 
such  as  has  always  been  present  to  our  minds  while 
examining  our  wounded  patients,  we  are  of  opinion  that 
we  should  call  attention  particularly  to  a  variety  which 
we  have  ascertained  to  follow  fractures  of  the  orbit. 
It  is  a  matter  of  an  affection,  very  different  on  the 
whole,  from  those  described  by  authors.  We  propose 
to  call  it  "  proliferating  choroido -retinitis,"  and  we 
proceed  to  give  the  description  of  it. 

(/5)  Traumatic  Proliferating  Choroido-retinitis 

Choroido -retinitis  follows,  not  haemorrhages  into  the 
vitreous  body,  such  as  the  relapsing  haemorrhages  of 
adolescents,  but  haemorrhages  of  the  retina  and  choroid 
due  to  lacerations. 

This  traumatic  proliferating  retinitis  results  from  the 
organisation  of  effusions  which  are  situated  outside  the 
vitreous.  Here  is  a  characteristic  which  distinguishes 
this  affection  from  the  proliferating  retinitis  compli- 


PRESERVATION  OF  THE  EYEBALL         911 

eating  the  relapsing  hsemorrhages  of  the  vitreous  of 
adolescents.  There  the  disorders  belong  to  the  vitre- 
ous ;  a  retinal  vessel  bleeds  in  the  eye,  the  first  intra- 
ocular epistaxis  is  absorbed,  the  second  leaves  behind 
some  traces,  and  after  the  third  or  fourth  relapse  the 
effused  blood  ends  by  becoming  organised,  by  the  aid 
of  the  elements  of  the  most  internal  layer  of  the  retina 
(fibres  of  Muller,  perivascular  mesodermic  tissue), 
which,  when  irritated,  proliferates  and  gives  birth  to 
the  great  fibrous  tracts  which  the  classic  authorities 
have  taught  us  to  recognise,  and  which  trespass,  not 
only  on  the  most  internal  parts  of  the  retina,  but  also  on 
the  peripheral  layers  of  the  vitreous  body. 

The  conditions  of  the  proliferating  choroido -retinitis 
of  our  wounded  are  quite  otherwise  ;  in  their  case  there 
is  no  relapse,  the  vessels  which  bleed  do  not  proceed 
from  the  retina,  nor  do  the  proliferation  and  post- 
hsemorrhagic  organisation  of  the  connective  tissue  ;  the 
seat  of  the  trouble  is  not  retino -vitreous. 

Under  the  influence  of  shock  or  of  ocular  concussion 
a  rupture  of  the  uveal  tract  and  of  the  retina  has  taken 
place  ;  there  has  been  a  more  or  less  extensive  effusion 
into  the  meshes  of  these  membranes.  Ts  it  small 
in  quantity  ?  Then  it  will  be  absorbed,  and  the  cho- 
roido-retinal  scar  will  take  on  the  appearance  so  well 
known  as  atrophic  and  pigmented  choroido -retinitis. 
Is  the  amount  of  blood  more  considerable  ?  The  vitre- 
ous may  then  be  implicated,  but  the  clots  which  are  in 
its  meshes  rapidly  disappear.  But  the  haemorrhage, 
on  the  contrary,  which  in  these  cases  is  present  in  the 
whole  thickness  of  the  retino -ctoroid  and  in  the  retino - 
vitreous  space,  experiences  much  difficulty  in  becoming 
absorbed ;  it  becomes  organised,  at  the  same  time  pro- 
voking irritation  of  the  connective  tissue  of  the  uveal 
tract  in  the  region  of  the  rupture.  The  connective 
tissue  proliferation  takes  place  at  its  expense,  and  re- 
sults in  the  formation  of  fibrous  tracts,  which,  at  first 
slight,  might  be  taken  for  proliferating  retinitis,  properly 
so-called.  We  see  therefore  that  traumatic  prolifera- 
ting retinitis   differs  much   from  the  classic  type  as 


912  FRACTURES  OF  THE  ORBIT 

regards  its  situation.  We  have  to  deal,  in  our  soldiers, 
with  a  proliferating  choroido-retinitis,  the  choroid 
participating  in  fact  in  its  formation  as  much  as  the 
retina,  and  even  more  than  the  retina  itself. 

We  are  dealing,  therefore,  with  a  choroido -retinal 
cicatricial  process  secondary  to  the  rupture  or  laceration 
of  these  membranes,  and  this  statement  will  explain 
why  the  papillo -macular  region  should  be  the  habitual 
seat,  since  it  is  also  that  of  the  traumatic  choroido- 
retinal  disorders  sequent  to  orbital  fractures. 

One  of  the  appearances  which  best  demonstrates 
this  is  offered  by  the  disc  when  a  projectile  has  caused 
avulsion  of  the  optic  nerve.  The  papillary  hole  which 
follows  this  tearing-out  is  filled  up  little  by  little  by  a 
proliferating  connective  tissue  formation  in  which 
the  peripapillary  uveal  tract,  infiltrated  by  great 
hsemorrhagic  patches,  participates  with  the  papilla 
(see  Plates  III  and  IV). 

Being  cicatricial  tissue,  the  result  is  that  traumatic 
proliferating  choroido-retinitis,  once  organised,  cannot 
be  modified.  The  loss  of  vision,  more  or  less  complete, 
the  modifications  of  the  visaal  field  which  follow,  are 
definitive.  Retinal  detachments,  which  are  caused  by 
secondary  traction  of  the  retina  towards  the  vitreous, 
by  the  contraction  of  the  fibrous  vitreo -retinal  cords, 
are  common  in  proliferating  retinitis,  since  in  this 
affection  the  disorganisation  concerns  the  deep  layers 
of  the  retina,  and  especially  the  uveal  tract,  to  which 
this  membrane  is  simply  applied.  But  with  our  soldiers 
the  cicatrix  involves  both  retina  and  choroid ;  the 
organised  patches  intimately  attach  the  retina  to  the 
underlying  ocular  membranes,  and  thus  prevent  slow 
detachment. 

Ophthalmoscopic  appearances. — From  the  ophthal- 
moscopic point  of  view  its  characters  are  as  follow : 
a  greyish  white  mass  surrounded  by  a  zone  more 
or  less  extensive,  sometimes  very  large,  blackish, 
pigmented  (Fig.  44) ;  this  mass  is  raised,  a  fact  which 
testifier:  to  the  proliferation  of  the  connective  tissue ; 
the  retinal  vessels  are  seen  to  pass  over  it,  turning  out 


PRESERVATION  OF  THE  EYEBALL 


913 


of  the  direct  line  to  do  so  (Plate  IV,  Fig.  3) ;  vessels  too 
pass  underneath,  some  are  seen  to  perforate  it,  forming 
loops  which  project  forwards  (Plate  III,  Fig.  2). 

In  Plate  IV,  Fig.  1,  below  the  atrophied  disc  can  be 
distinguished  a  raised  white  patch,  upon  which  climb 
vessels  emerging  from  the  papilla  and  making  a  visible 


Fig.  44. — Fracture  of  the  left  frontal  sinus;  eyeball  contused 
by  the  inferior  wall  of  the  sinus  thrust  downwards.  Proliferating 
re tino -choroiditis  of  the  posterior  pole  implicating  the  macular 
region. 


bend,  precisely  at  the  moment  when  they  mount  upon 
this  elevation ;  whilst  these  retinal  vessels  are  mani- 
festly situated  above  and  in  front  of  the  plaque  of 
proliferating  newly-formed  tissue,  other  vessels  traverse 
the  plaque  in  the  middle  of  its  substance,  and  others 
pass  beneath. 

The  two  figures  (Fig.  35 ;   Plate  III,  Fig.    1,  papil- 
lary avulsion)  are  amongst  the  most  interesting  of  our 


914  FRACTURES  OF  THE  ORBIT 

collection ;  they  have  to  do  with  a  total  or  subtotal 
avulsion  of  the  disc. 

The  first  deals  with  a  partial  tearing-away,  affecting 
the  upper  part  of  the  papilla  (inverted  image) ;  the 
half  of  the  disc  which  has  been  torn  away  is  covered 
by  new  formation,  whence  the  vessels  spring ;  it  is 
remarkable  that  this  fibroid  mass  is  not  everywhere 
sufficiently  prominent  to  fill  the  fossa  created  by 
the  papillary  avulsion ;  it  is  only  exuberant  in  its 
inferior  portion ;  at  the  upper  part  it  is  still  upon 
a  plane  deeper  than  the  rest  of  the  fundus  of  the  eye. 
The  other  figure  is  a  truly  admirable  example  of  total 
avulsion  of  the  papilla,  a  papillary  detachment  which 
is  accompanied  by  two  lacerations  starting  from  the 
macula,  the  one  above  and  to  the  outer  side,  the  other 
down  and  in ;  there  is  a  third  tear  in  the  macular  region. 
All  around  the  disc  the  choroido -retinal  lacerations 
have  proliferated,  but  the  excavation  has  not  been  filled 
up;  there  remains  a  cavity  recalling  the  ophthalmo- 
scopic image  of  certain  cases  of  chronic  senile  glaucoma ; 
there  has  been  a  true  avulsion  of  the  papilla  in  the 
correct  sense  of  the  word. 

Often  the  .laceration  of  the  choroid  and  retina,which 
entails  the  proliferation,  is  seated  exclusively  in  the 
macular  region  (Plate  IV,  Fig.  2);  the  mass  of  new 
formation  then  has  no  direct  relation  to  the  larger  ves- 
sels ;  it  takes  the  form  of  a  fibrous  "  cake,"  irregularly 
star-like  (Plate  III,  Fig.  2) ;  or  of  the  arc  of  a  circle, 
(Plate  IV,  Fig.  4);  frequently  around  this  fibrous 
"  cake  "  is  found  a  pigmented  zone,  indicating  the 
considerable  participation  of  the  uveal  tract  in  the 
proliferation. 

The  figures  which  represent  this  proliferating  cho- 
roido-retinitis,  in  addition  to  all  those  of  Plates  I,  II, 
III  and  IV,  have  been  drawn  from  nature  by  M.  Pesme, 
student  of  medicine,  hospital  orderly  in  the  service, 
to  whom  we  desire  here  to  render  thanks. 


PRESERVATION  OF  THE  EYEBALL 


915 


Comparative  Table  showing  the  Differences 
BETWEEN  Proliferating  Retinitis  and  Traumatic 
Proliferating  Choroido-retinitis. 


Retinitis  Proliferans 

Proliferation  due  to  or- 
ganisation of  effused  blood ; 
may  be  produced  without 
previous  haemorrhage. 

Membranes  with  multiple 
prolongations ;  appearance 
of  a  spider's  web  spread 
over  a  large  portion  of  the 
fundus  of  the  eye. 

Membranes  translucent  in 
certain  points. 

Projections  ending  free 
in  the  vitreous. 

Masses,  pedunculated, 
polymorphous,  with  uneven 
surface,  outline  well  marked. 

Situated  in  all  parts  of 
the  retina. 

Focus  of  pigmentation 
very  frequently  around  the 
membranes. 

Often  complicated  by  de- 
tachment of  the  retina,  due 
to  traction  of  the  vitreous 
bands. 


Traumatic  Proliferating 
Choroido-retinitis 

Always  consecutive  to  a 
haemorrhage  and  a  rupture 
of  the  deep  membranes. 

Fibrous  plaque,  more 
localised,  of  a  more  regular 
thickness. 


Everywhere  opaque. 

Simple  relation  of  pro- 
pinquity with  the  vitreous 
body. 

No  very  prominent  mas- 
ses in  the  vitreous  body; 
even  surface,  projecting 
moderately. 

Much  more  common  in 
the  macula,  the  disc  and 
its  circumference. 

Foci  of  pigmentation  very 
frequent. 

Is  not  accompanied  by 
detachment  consecutive  to 
the  proliferation,  which,  on 
the  contrary,  attaches  the 
retina  to  the  choroid. 


{y)    Traumatic  Detachment  of  the  Retina 

In  this  class  of  retinal  detachments  we  may  admit 
several  varieties  which  can  be  succinctly  enumerated 
thus. 

(1)  Detachment  by  subretinal  haemorrhage. 


916  FRACTURES  OF  THE  ORBIT 

(2)  Detachment  by  post -traumatic  retraction  of  the 
vitreous  body. 

(3)  Detachment  which  results  from  the  cicatricial 
contraction  of  a  wound, 

(4)  That  which  follows  a  loss  of  vitreous, 

(5)  That  which  results  from  concussion  at  a  distance, 
with  or  without  laceration  of  the  retina. 

We  have  met  with  all  these  varieties,  and  we  have 
noted  forty  retinal  detachments  amongst  our  hospital 
cases;  a  very  frequent  form  is  the  detachment  by 
concussion. 

The  shock  upon  the  eye  causes  a  subretinal  haemor- 
rhage and  a  laceration  of  the  retina  and  choroid  ;  three 
months  afterwards  one  finds  a  large  plaque  of  atrophy 
and  not  a  detachment  of  the  membrane. 

We  have  rarely  met  with  this  affection  in  the  cases 
of  foreign  bodies  of  the  orbit ;  amongst  our  cases  we 
can  recall  only  one  (Case  24,  Fig.  30)  in  which  a  piece 
of  shell  injured  the  external  orbital  process,  result- 
ing in  a  profuse  vitreous  haemorrhage,  which  after 
a  certain  time  allowed  large  detachments  to  be  seen, 
one  peripheral  to  the  external  equatorial  portion,  the 
other  in  the  macular  region.  There  was  a  shell  frag- 
ment below  the  eye ;  this  fragment  must  have  contused 
the  organ  and  a  great  part  of  the  derangements  should 
be  attributed  to  direct  shock.  But  it  should  also  be 
remarked  that  a  violent  contusion,  the  fracture  of  the 
external  orbital  process,  must  have  set  up  in  the  eye 
concussion  quite  sufficient  in  itself  to  produce  the 
detachment  of  the  retina. 

The  number  of  cases  of  retinal  detachment  caused  by 
simple  concussion  at  a  distance  is  not  very  considerable, 
but  we  believe  nevertheless  that  we  ought  to  draw  atten- 
tion to  this  type  of  disorder  because  of  this  special 
pathogeny. 

We  have  four  cases  to  quote  :  the  two  first  are  Cases 
15  and  16,  in  which  the  projectile  traversed  the  facial 
mass  from  one  side  to  the  other,  without  lesion  of  the 
eyeball,  and  provoked,  in  the  first,  retinal  detachment 
at  the  inferior  part  of  both  eyes,  in  the  second,  detach- 


PRESERVATION  OF  THE  EYEBALL  917 

ment  at  the  infero -external  portion  of  one  eye.  The  two 
other  cases  are  identical  as  to  pathogeny,  although  they 
deal  with  two  fractures  of  the  external  wall  of  the  orbit, 
which  have  brought  about  total  detachment  of  the 
retina  on  the  side  of  the  fracture. 

In  relation  to  these  four  cases,  moreover,  we  can 
bring  forward  two  others  in  which  there  was  no  fracture 
of  the  orbit,  but,  as  a  result  of  simple  displacement  of 
air,  caused  by  the  near  explosion  of  a  shell,  the  two 
cases  were  affected,  one  on  the  right  side,  the  other 
on  the  left,  with  detachment  limited  to  the  inferior 
portion  of  the  retina,  without  direct  shock  to  the 
globe. 

We  have  considered  it  our  duty  to  chronicle  this 
variety  of  traumatic  detachment  here  with  some 
details,  for  it  is  less  common  than  the  other  forms  of 
this  condition. 

We  do  not  think  we  need  insist  upon  the  varieties 
which  result  from  subretinal  traumatic  haemorrhages, 
nor  upon  the  detachments  consecutive  to  fibrous 
organisation  of  the  vitreous  body ;  what  we  have 
said  on  proliferating  retinitis,  and  all  that  the  authori- 
ties have  taught  oh  this  subject,  will  certainly  be 
prominent  in  the  mind  of  the  reader. 

Practical  considerations  on  the  prognosis  and  treat- 
ment of  this  kind  of  lesion  will  be  foiind  later  in  the 
book.  (See  Treatment  of  Fractures  of  the  Orbit  and 
their  Complications.) 

E. — Traumatic  Enophthalmos 

Enophthalmos  is  a  symptom  which  occurs  in  a 
certain  number  of  varied  conditions,  and  too  many 
authors  have  sought  to  give  it  a  single  pathogenesis, 
as  if  it  were  a  question  of  an  affection  always  the 
same  and  well  defined. 

Sinking  of  the  eye  in  the  orbit  may  happen  under  a 
great  number  of  circumstances,  all  different : — 

(I)  When  the  means  of  suspension,  passive  or 
active,  of  the  eye  are  torn  or  paralysed ;   the  capsule 


918  FRACTURES  OF  THE  ORBIT 

of  Tenon  ruptured ;  the  oblique  muscles  paralysed ; 
or  when  the  recti  muscles  are  retracted. 

(2)  When  the  cervical  sympathetic  is  paralysed  by 
too  prolonged  action  or  excitation. 

(3)  When  after  a  profuse  haemorrhage  of  the  orbit 
or  chronic  inflammation  of  the  cellulo -adipose  tissue 
there  occurs  cicatricial  retraction  of  the  retro -bulbar 
tissue. 

(4)  When  trophic  troubles  occur,  involving  absorp- 
tion of  the  cellulo -adipose  tissue. 

(5)  When  the  orbital  cavity  is  enlarged  by  a 
fracture  which  produces  a  depression  of  any  one  of 
its  walls. 

The  fact  is  that  enophthalmos  may  occur  whenever 
there  is  default  of  any  of  the  forces  which  maintain 
the  eye  in  the  exact  eqxiilibrium  which  is  normal  to 
it.  These  forces  are  the  following:  (1)  the  traction 
backwards  of  the  recti  muscles  and  the  traction 
forwards  of  the  oblique  muscles ;  (2)  the  capsule  of 
Tenon  and  the  smooth-fibred  muscle  of  MtrLLER, 
which  represent  an  active  element  capable  of  being 
immediately  modified  by  the  excitation  or  the  paralysis 
of  the  sympathetic ;  (3)  the  cellulo -adipose  cushion 
upon  which  the  eye  rests ;  (4)  lastly,  the  bony  cavity 
whose  firmly  fixed  walls  give  stability  and  rigidity  to 
the  visu^d  apparatus. 

It  is  obvious  that  these  diverse  conditions  of  the 
ocular  equilibrium,  when  modified,  may  bring  about 
enophthalmos,  and  that  each  getiological  variety  corre- 
sponds with  the  clinical  varieties  we  have  met  with 
amongst  our  wounded. 

We  shall  pass  in  review  each  of  these  varieties,  laying 
under  contribution  what  has  been  said  by  the. different 
writers  who  have  busied  themselves  with  the  question, 
and  utilising  the  cases  we  have  collected. 

(I)  The  enophthalmos  which  results  from  defective 
equilibrium  between  traction  of  the  recti  muscles 
behind  and  the  obliques  in  front  is  the  rarest  form ; 
we  do  not  think  it  exists  in  the  science  of  ascertained 
facts ;  a  prierij  it  is  evident  that  paralysis  of  the  two 


PRESERVATION  OF  THE  EYEBALL         919 

obliques  should  be  followed  by  a  retreat  of  the  eyeball ; 
but,  clinically,  paralysis  of  the  pathetic  and  of  the 
branch  of  the  oculo -motor  destined  for  the  inferior 
oblique  must  be  extremely  rare,  and  this  variety  should 
be  looked  upon  as  so  exceptional  that  in  ordinary 
practice  it  need  not  be  considered. 

It  is,  however,  not  only  the  muscles,  the  active 
ligaments,  which  maintain  the  eye  in  position ;  there 
is  also  the  action  of  the  aponeuroses  and  passive 
ligaments  in  the  ocular  enarthrosis ;  the  means  of 
suspension  may  be  torn  or  dislocated  by  traumatism. 
PiCHLER  admits  in  the  aetiology  of  the  affection  the 
rupture  of  the  septum  orhitale ;  Kilbrun  {Archives 
d'Ophtalmologie,  1902)  reports  the  case  of  a  man  who, 
ten  days  after  having  fallen  from  a  sledge,  presented 
ptosis  by  enophthalmos,  and  explains  his  case  by 
laceration  of  Tenon's  capsule,  or  its  ligamentous 
appendages. 

Such  aetiological  conditions  must  be  very  rare ;  we 
have  not  seen  them  amongst  our  patients,  and  in  the 
great  majority  of  cases  it  is  to  the  other  mechanisms, 
previously  enumerated,  that  we  must  look  for  the 
processes  capable  of  explaining  enophthalmos. 

(2)  The  paralysis  of  the  unstriped  muscle  of 
MuLLER  is  a  cause  of  enophthalmos,  and  it  will  be 
fitting  here  to  give  some  anatomical  and  physiological 
details. 

This  muscle,  upon  which,  after  Mt^LLER,  Sappey  has 
insisted,  is  a  layer,  fibrous  in  appearance,  but  in  reality 
muscular,  extending  transversely  from  the  internal  to 
the  external  part  of  the  orbit,  continuous  below  with 
the  adherent  border  of  the  tarsal  cartilage  and  giving 
insertion  above  to  the  levator  palpebrae  and  to  the 
subjacent  prolongation  of  the  orbital  fascia.  It  has  a 
fixed  origin  and  a  mobile  insertion,  like  all  muscles ; 
its  origin,  by  its  union  with  the  levator,  corresponds 
to  the  apex  of  the  orbit  and  its  insertion  is  the  adherent 
margin  of  the  tarsal  cartilage. 

Into  its  constitution  enter  a  great  number  of  lami- 
nated fibres  and  of  elastic  fibres,  but  these  are  only 


920  FRACTURES  OF  THE  ORBIT 

accessory  elements  ;  the  fundamental  elements  are  the 
unstriped  muscular  fibres. 

The  bundles  Avhich  form  the  median  portion  are 
directed  from  above  downwards,  the  divisions  inter- 
lacing and  forming  a  sort  of  network  with  irregularly 
elliptical  meshes.  This  muscle  represents  a  segment  of 
a  hollow  sphere  which  surrounds  the  eye  over  a  large 
portion  of  its  area. 

There  is  also  a  MiJLLER's  muscle  in  the  lower  eyelid  ; 
its  attachments  are,  on  the  one  hand  the  deep  surface 
of  the  palpebral  expansion  of  the  tendon  of  the  inferior 
rectus  muscle,  on  the  other  hand  the  convex  margin 
of  the  tarsal  cartilage ;  at  the  level  of  the  inferior 
fornix  of  the  conjunctiva  it  splits  into  two  layers  : 
one,  palpebral,  which  goes  to  the  tarsal  cartilage,  the 
other  going  between  the  bulbar  conjunctiva  and  the 
eyeball. 

MtJLt.ER's  muscle  contains  groups  of  nerve-cells 
analogous  to  ganglionic  nerve  cells,  in  such  a  manner 
that  it  possesses  its  own  innervation,  independent  of 
the  oculo-motor  which  innervates  the  levator  palpebrse. 

It  is  innervated  by  the  cervical  sympathetic.  When 
this  nerve  is  divided  MtJLLER's  muscle  is  paralysed, 
and,  the  eye  sinking  back  into  the  orbit,  the  patient 
has  enophthalmos.  Excitation  of  the  sympathetic,  by 
exaggeration  of  the  action  of  the  muscle,  produces 
exophthalmos.  It  must  therefore  be  admitted  that, 
according  to  physiology,  the  unstriped  muscular 
fibres,  which  form  the  muscle  of  which  we  are  speak- 
ing, surround  the  eye,  pass  behind  its  equator,  and, 
in  contracting,  push  it  forwards.  The  anatomical 
description  given  above,  although  strictly  according  to 
the  authorities,  does  not  make  the  action  of  the  muscle 
clear  to  the  comprehension ;  it  is  more  than  probable 
that  smooth  muscular  fibres  exist  right  into  the  cap- 
sule of  Tenon,  facing  the  posterior  hemisphere  of  the 
ocular  globe,  for  without  them  we  confess  that  we  fail 
to  understand  the  physiological  action  of  the  muscle 

of   MtJLLER. 

The  description  which  the  anatomists  give   shows 


PRESERVATION  OF  THE  EYEBALL 


921 


why  excitation  of  the  sympathetic,  acting  upon  the 
muscle,  increases  the  palpebral  opening,  whilst  section 
of  the  sympathetic  closes  that  opening ;  but  it  in  no 
way  enables  us  to  understand  why  the  subject  should 
become  exophthalmic  in  the  first  case  and  enophthalmic 
in  the  second. 

We  present  these  reflections  to  the  anatomists  and 
physiologists  in  passing. 

Here  we  publish  a  case  of  enophthalmos  due  to 
section  of  the  cervical  sympathetic  by  shrapnel. 

Section  of  the  sympathetic  by  a  shrapnel  ball ;   enophthalmos  ; 
Claude  Bernard's  syndrome  ;    recovery.    (Case  39.) 

P.  L.,  aged  22  years,  Infantry,  was  wounded  Sep.  5 
by  two  shrapnel  balls.  One  struck  him  in  the  arm,  the 
other  in  the  neck,  at  the  level  of  the  fourth  cervical.     It 


Fig.  45. 


penetrated  the  right  side  at  the  posterior  border  of  the 
sterno-cleido-mastoid,  and  taking  a  horizontal  course,  came 
to  rest  in  the  left  carotid  region. 

The  orifice  of  entry  is  narrow  and  has  not  bled,  but 
immediately  after  the  injury  L.  spat  blood.  Pharyngeal 
haemorrhages  occurred  for  several  days ;  at  the  same  time 
the  patient  swallowed  with  difficulty  and  experienced  a 
burning  sensation  in  the  pharynx.  The  pharynx,  there- 
fore,  has   been  traversed   by  the  ball.     The  left   carotid 


922  FRACTURES  OF  THE  ORBIT 

region,  where  it  is  lodged,  presented  for  some  time  a  lively 
inflammatory  reaction,  but  the  ball  was  soon  discovered 
by  palpation,  and  extracted  by  an  incision  similar  to  that 
used  for  ligature  of  the  carotid. 

It  was  then  that  the  case  was  sent  to  us.  There  is 
marked  enophthalrtios  of  the  right  eye.  The  palpebral 
fissure  is  narrowed,  the  pupil  in  a  condition  of  miosis. 
L.  states  that  his  eye  has  been  very  red,  that  he  has  had  a 
sensation  of  gritty  particles  in  the  conjunctiva,  and  that 
there  was  running  of  the  eyes  directly  after  the  injury,  but 
that  these  symptoms  have  disappeared. 

Visual  acuity  equal  to  unity ;  visual  field  intact. 

The  left  eye  is  healthy.  There  is  nothing  abnormal  to 
be  found  in  the  spheres  of  action  of  the  glosso-pharyngeal, 
pneumogastric,  spinal  accessory,  and  hypoglossal  nerves. 
The  enophthalmos  rapidly  diminished,  and  the  case  only 
presented  a  slight  narrowing  of  the  palpebral  fissure  when 
he  was  discharged,  Dec.  31,  1914. 

In  this  case  is  realised,  in  the  clearest  manner,  the 
experiment  of  Pourfour  du  Petit  and  of  Claude 
Bernard;  a  well-known  fact  is  noted,  to  wit,  that 
the  greater  portion  of  the  ocular  results  of  section  of 
the  sympathetic  are  transitory ;  of  this  number  is  the 
enophthalmos,  which,  strongly  marked  at  the  time  of 
the  accident,  had  completely  disappeared  four  months 
later.  It  must  not  be  thought  that,  under  such  cir- 
cumstances, the  enophthalmos  is  only  apparent,  and 
due  solely  to  the  peculiar  appearance  given  to  the 
eye  by  the  narrowing  of  the  palpebral  aperture ;  the 
enophthalmos  is  very  real.  The  eye  is  carried  back- 
wards in  a  very  definite  manner,  as  though -one  of  the 
forces  which  draw  it  forwards  had  suddenly  failed  to 
act.  It  is  this  action  upon  the  globe,  well  demon- 
strated by  physiologists  and  by  clinical  experience  (as 
our  case  testifies),  which  the  anatomical  study  of 
Muller's  muscle  would  not  teach  us  to  foresee. 

(3)  Enophthalmos,  due  to  paralysis  of  Muller's 
muscle,  is  rapid — so  to  speak,  immediate — when  the 
cervical  sympathetic  is  divided.  In  the  classic  experi- 
ments of  Pourfour  du  Petit  and  Claude  Bernard, 


PRESERVATION^  OF  THE  EYEBALL        923 

retraction  of  the  eyeball  is  part  of  the  paralytic 
syndrome  of  the  cervical  sympathetic,  but  this  enoph- 
thalmos,  which  the  surgeon  who  resects  the  superior 
cervical  ganglion  for  the  cure  of  glaucoma,  for  example, 
(JoNNESCO,  Abadie,  ctc.)  produccs  in  spite  of  himself, 
Is  still  very  rarely  observed  clinically  as  a  sequence  of 
accidents  which  happen  to  the  orbit  and  its  contents. 
The  case  we  have  just  reported  is,  perhaps,  unique  in 
science. 

The  nervous  theory  of  enophthalmos  should  be 
extended  to  cover  the  trophic  disturbances  which 
lesions  of  the  sympathetic  entail  upon  the  nutrition  of 
the  cell ulo -adipose  tissue  upon  which  the  eye  rests. 
When  vaso -motor  innervation  is  at  fault  the  orbital 
tissues  are  badly  nourished,  become  less  solid,  and  the 
eye  follows  them  in  their  retraction ;  this  theory  has 
already  been  defended  by  Beer  in  1893.  In  a  patient, 
kicked  by  a  horse,  without  the  orbital  waUs  being 
enlarged  or  driven  in,  there  appeared  a  well-marked 
enophthalmos  which  this  writer  attributed  to  rare- 
faction of  osseous  tissue.  Purtscher  has  also  adopted 
this  view;  he  very  properly  remarks  that  there  is 
only  true  enophthalmos  in  cases  where  there  is  no 
depression  of  the  orbital  walls  or  cicatricial  bands ; 
true  enophthalmos,  strictly  speaking,  as  in  our  cases, 
Nos.  40,  41,  42,  is  that  which  is  produced  in  an  orbit 
in  which  the  cellulo -adipose  mass  has  lost  its  normal 
volume  as  a  sequence  to  faulty  innervation. 

The  cases  in  which  the  appearance  of  profuse 
haemorrhage  has  been  noted  at  the  moment  of  trau- 
matism, causing  at  first  exophthalmos,  and  afterwards 
enophthalmos  by  cicatricial  organisation  of  the  clot, 
are  no  longer  to  be  considered  pure  cases.  These 
pure  cases  of  enophthalmos,  those  which  we  may  look 
upon  as  cases  of  essential  enophthalmos,  are  those 
which  correspond  to  simple  atrophy  of  neuro -trophic 
origin.  When  the  enophthalmos  is  preceded  by  a  clot 
becoming  organised  and  retracting  in  the  orbit,  or 
still  more  when  cellulitis  has  previously  developed,  a 
particular  variety  is  in  question,  having,  m  a  way,  a 


924  FRACTURES  OF  THE  ORBIT 

mechanical  origin ;  this  form  is  rare,  we  have  not 
seen  it  in  either  civil  or  military  practice.  The 
mobility  of  the  globe,  well  preserved  in  general,  and 
the  rapidity  with  whicK  the  enophthalmos  appears  do 
not  accord  with  the  organisation,  always  leisurely,  of 
cicatricial  tissue.  Cohn  is  the  sole  author  who  has 
insisted  upon  the  limitation  of  the  movements  of  the 
globe,  which  he  found  in  one  case  adherent  to  the 
surrounding  parts.  With  all  our  patients,  as  in  all 
the  cases  of  which  we  have  been  able  to  read  the 
reports,  the  ocular  movements  have  preserved  all 
the  freedom  compatible  with  the  vicious  position 
occupied  by  the  organ  in  the  orbit. 

It  results  from  what  has  been  said  that  the 
great  majority  of  cases  of  sympathetic  enophthalmos 
should  be  explained  by  trophic  derangements  due  to 
disorders  bearing  upon  the  innervation  of  the  orbit, 
and  we  do  not  see  wherefore  certain  authors  maintain 
absolutely  that  a  fracture  of  the  orbit  exists  (Morax, 
Chaillous).  Doubtless  in  violent  orbital  traumatism, 
by  contusion  most  frequently,  a  fissure  will  exist  in 
the  orbital  walls,  and,  even  in  fractures  by  projectiles 
of  war,  the  lesion  will  be  always  more  or  less  marked ; 
but  in  the  case^  of  essential  enophthalmos,  of  true 
enophthalmos,  the  osseous  lesion  will  hold  an  accessory 
and  relative  place ;  otherwise,  in  all  orbital  fractures 
in  military  surgery,  there  would  be  enophthalmos. 
We  are  confronted  by  quite  different  clinical  facts, 
because  out  of  several  hundreds  of  orbital  fractures 
we  have  only  been  able  to  find  four  cases  of  traumatic 
enophthalmos.  These  are  fractures  affecting  the 
ciliary  ganglion  or  the  carotid  plexus  which  enters  the 
orbit  with  the  ophthalmic  artery,  and  they  are  accom- 
panied by  true  enophthalmos.  It  is  not  the  fracture 
which  matters;  what  does  matter  is  the  lesion  of 
nerves  capable  of  interfering  with  the  nutrition  of  the 
retro-bulbar  cellulo -adipose  tissue. 

Here  are  three  unpublished  cases  of  traumatic 
enophthalmos  from  trophic  troubles. 


PRESERVATION  OF   THE  EYEBALL         925 

Fracture  of  the  right  orbit ;   traumatic  enophthalmos 
consecutive  to  trophic  troubles.    (Case  40.) 

H.  G.,  Infantry,  wounded  at  M.,  July  5,  1915,  by  a  fall 
from  the  edge  of  a  trench,  due  to  the  explosion  of  a  shell. 
He  lost  consciousness  for  three  or  four  minutes ;  he  was 
immediately  sent  to  be  treated  at  T.  Sent  back  to  the 
front  twenty  days  later,  he  had  two  successive  attacks  of 
giddiness,  and  came  via  Chalons  to  Bordeaux,  where  he 
was  admitted  Sep.  5,  1915. 

Case-sheet  on  entry  :  '"  Fracture  of  right  orbit  from 
fall  on  the  right  orbito-ocular  region,  with  wound  over  the 
superior  orbital  margin  and  detachment  of  upper  eyelid." 

Examination.— March  12,  1916,  the  right  palpebral 
fissure  has  its  opening  diminished  by  retraction  of  the 
eyebaU.  This  latter,  in  fact,  is  sunk  at  least  4  mm.  This 
enophthalmos  is  not  the  consequence  of  depression  of  the 
walls  of  the  orbit,  as  is  evidenced  by  radiography.  It  is 
due,  it  seems,  to  trophic  disturbance  of  the  orbital  con- 
tents, thus  realising  the  classic  type  of  traumatic  enoph- 
thalmos by  derangement  of  nutrition. 

There  is  paresis  of  the  external  rectus  muscle,  the 
superior  rectus,  and  the  inferior  oblique,  causing  well- 
marked  homonymous  diplopia. 

There  is  probably  a  nerve  lesion  caused  by  the  fracture 
having  injured  at  the  apex  of  the  orbit,  in  the  sphenoidal 
fissure,  filaments  of  the  sympathetic  at  the  -same  time  as 
the  motor  nerves. 

The  right  eye  has  normal  tension.  The  pupil  reacts 
perfectly,  directly  and  consensually ;  there  is  no  lesion  of 
the  deep  membranes  or  of  the  transi)arent  media.  Acuity 
equals  7/10  with  a  spherical  convex  of  -|-  1  D. 

The  left  eye  is  normal,  V  =  10/10. 

This  condition  has  remained  stationary  up  to  to-day 
(May  25,  1916). 

Contusion  of  the  left  orbital  region,  probably  fracture  ;  traumatic 
enophthalmos  of  the  left  eye  :  consecutive  trophic  troubles. 

(Case  41.) 

E.  R.,  wounded  Nov.  16,  1915,  at  bombing  exercise,  at 
H.     Sent  by  medical  board  Sep.  24,  1916. 

Examination. — R.  presents  at  the  level  of  the  left  upper 
eyelid    a    cicatricial    wound    resulting    from    the    violent 


926 


FRACTURES  OF  THE  ORBIT 


traumatism  suffered  by  the  orbito-ocular  region  at  the 
moment  of  bursting  of  the  grenade.  The  soft  parts  of  the 
orbit,  including  the  globe  of  the  eye,  have  been  severely 
contused  by  displacement  of  air;  as  concerns  the  orbit, 
there  have  resulted  trophic  troubles  ending  in  the  dis- 
appearance of  the  retro-  and  circum-ocular  adipose  cushion, 
and  producing  sinking  of  the  globe  in  the  orbital  cavity. 

This  enophthalmos,  very  marked,  is  accompanied  by 
ptosis  of  the  upper  eyelid,  due  partly  to  paralysis  of  the 
levator,  partly  te  the  retraction  of  the  globe. 


Fia.  46. 


Radiography  shows  that  there  is  no  intra-orbital  pro- 
jectile. But,  by  touch  alone,  it  is  easy  to  localise  in  the 
left  front o-parietal  region  a  large  piece  of  shell,  encrusted 
in  the  bony  wall  (Fig.  47).  It  is  impossible  to  make  certain 
by  radiography  if  there  is  a  fracture  irradiated  to  the  vault 
of  the  orbit,  recollecting  the  interval  of  time  between  the 
date  of  the  injury  and  our  examination.  The  presence  of 
the  fragment  shows  clearly,  however,  that  the  left  orbital 
region  was  in  the  sphere  of  action  of  the  traumatism. 

The  left  eye  is  on  the  way  to  atrophy.  There  is  a  total 
detachment  of  the  retina,  with  the  exception  of  a  small 
segment  of  the  infero-internal  region. 

Ocular  tension  lessened  :  T  —  2. 

Right  eye  normal,  V  =  10/10. 


PRESERVATION  OF  THE  EYEBALL         927 

No  disturbance  in  the  transparent  media;  examination 
of  the  deep  membranes  reveals  to  us  no  lesion. 


Paralysis  of  the  external  rectus  and  consecutive  trophic  troubles 
(enophthalmos).    (Case  42.) 

R.,  Dragoon,  kick  of  horse,  Nov.  28,  1897,  under  the 
following  conditions.  Wishing  to  pick  up  a  snaffle  lying 
on  the  ground  in  the  stable,  about  50  cm.  froYn  his  mare, 


Fig.  47. 

at  the  moment  when  he  was  about  to  incline,  the  body 
being  almost  in  the  vertical  position,  save  for  a  slight 
bending  backwards  of  the  back,  R.  received  a  kick  a  little 
below  the  right  eye,  which  caused  a  wound  about  3  cm. 
long  by  5  mm.  wide ;  he  then  fell  heavily  upon  his  back, 
making  a  deep  wound  of  the  occipital  region,  about  a 
centimetre  in  diameter.     Nevertheless,   he  did  not  lose 


928  FRACTURES  OF   THE  ORBIT 

conscioiisneit  ,  and  was  assisted  by  two  comrades  to  \\alk 
to  hospital. 

In.  hospital  the  patient  presented  only  a  well-marked 
palpebro-conjunctival  ecchymosis,  in  addition  to  the  two 
wounds  which  were  sutured  and  dressed. 

At  the  end  of  a  month,  the  wounds  being  cicatrised, 
dressings  were  discontinued;  at  this  date,  he  complained 
of  diplopia. 

At  the  beginning  of  Jan.  1898,  the  date  when  he  came 
to  us,  he  had  evident  signs  of  paralysis  of  the  external 
rectus  of  the  right  eye,  with  contraction  of  the  antagonising 
muscle;  further,  the  face  is  thinner  on  the  damaged  side, 
and  the  eye  suffers  from  enophthalmos  :  V  =  1.  Emme- 
tropia  both  sides. 

No  trouble  of  accommodation.  Diagnosis  :  basilar 
paralysis  of  the  sixth  nerve. 

During  the  whole  of  the  year  1898,  R.  was  kept  under 
observation,  in  the  hope  that,  if  the  nerve  were  ^mply 
contused,  all  would  come  right ;  but  it  was  not  so.  With 
the  object  of  remedying  the  trophic  trouble,  thirty  sittings 
of  electrisation  with  continued  current  were  given.  The 
trophic  disturbances  were  a  little  improved. 

In  Jan.  1899,  more  than  a  year  after  the  accident,  the 
patient  had,  besides  his  enophthalmos,  a  very  unbecoming 
strabismus  which  caused  diplopia,  always  very  extensive 
and  very  tiresome. 

To  remedy  the  enophthalmos  and  correct  the  strabismus, 
Feb.  7,  1899,  we  performed  the  double  operation  of  cap- 
sular advancement  of  the  external  rectus  and  tenotomy 
of  the  internal. 

The  result  of  this  operation  was  excellent  in  this  sense, 
that  the  patient  had  no  longer  strabismus,  and  easily 
remedied,  by  turning  the  head,  the  diplopia  which  still 
existed  in  the  right  temporal  region.  He  easily  walked 
with  the  head  upright,  looking  straight  ahead  without 
seeing  double,  and  his  enophthalmos  had  disappeared. 

He  still  had  complete  paralysis  of  the  external  rectus 
of  the  right  eye,  but  the  inconveniences  of  this  paralysis 
are  reduced  to  the  minimum. 

(4)  We  arrive  at  last  at  a  variety  of  enophthalmos 
which  is  really  a  false  enophthalmos ;  it  is  that  which 
depends   upon   a   depression   of   one   of   the   walls   of 


PRESERVATION   OF   THE  EYEBALL         n'.) 

the  orbit,  causing  enlargement  of  its  cavity ;  it  is, 
indeed,  a  "  false  enophthalnios  "  if  we  reserve  the 
name  "  true  enophthalnios  "  to  that  which  results 
from  trophic  troubles ;  but  in  military  surgery  it  is 
the  form  most  frequently  met  with.  We  put  forward 
here  three  good  illustrations. 

The  eye,  acted  on  by  gravity,  may  fall  into  the 
maxillary  antrum,  or  be  thrust  there  by  the  wounding 
instrument  itself.  The  cases  of  Smetilts  de  Leda,  of 
Becker,  of  Langenbeck,  fall  into  the  same  category. 
It  is  also  by  fracture  that  Lang  explains  his  case ; 
he  thinks  that  the  orbit  is  enlarged  by  traumatism, 
and  that  the  eye  sinks  in  under  atmospheric  pressure ; 
Nagel  in  his  case  accepts  the  same  explanation.  The 
reality  of  this  mechanism  allows  of  no  doubt.  Nexjben, 
however,  is  wrong  in  wishing  to  apply  it  to  every  case. 
It  will  not  do  to  maintain  that  there  is  always  depression 
of  the  orbital  walls  in  enophthalmos  :  from  the  violence 
of  the  shock  there  may  be  frequently  an  osseous  fissure  ; 
but,  as  we  have  already  said,  it  is  not  this  fissure  which 
is  the  cause  of  the  sinking  in  of  the  eye. 

We  must  distinguish,  therefore,  two  principal  varie- 
ties of  enophthalmos — 

(1)  True  enophthalmos,  properly  so-called,  due  to  the 
nervous  troubles  which  we  have  placed  in  evidence, 
following  many  writers,  notably  Dr.  Daulnoy  and 
Prof.  Rohmer. 

(2)  False  traumatic  enophthalmos  from  enlargement 
of  the  orbital  cavity,  of  which  we  have  collected  three 
cases  which  we  report  here. 

Fracture  of  the  left  orbit ;  large  piece  of  shell  in  the  right  orbit ; 
atrophic  and  pigmentary  choroido-retlnitis.    (Case  43.) 

Commandant  R.,  Infantry,  wounded  Sep.  14,  1914,  at 
C,  by  a  shell.  From  F.  he  was  sent  to  us,  and  examined 
Oct.  26,  1915. 

Condition. — The  shell  fragment  has  penetrated  the  infero- 
external  portion  of  the  left  orbit,  where  there  is  a  scar 
3  cm.  in  length,  direction  vertical,  the  upper  extremity  of 
which  starts  from  the  external  canthus.     The  projectile  is 


930 


FRACTURES,  OF  THE  ORBIT 


lodged  in  the  right  ethmoido-orbital  region,  having  followed 
a  path  from  left  to  right  and  from  before  backwards.  It 
has  therefore  traversed,  first,  the  floor  of  the  left  orbit ; 
second,  the  left  orbit ;  third,  the  left  nasal  JPossa  and  the 
septum ;  fourth,  the  right  ethmoid,  and  the  internal  wall  of 
the  right  orbit. 

The  radiogram  of  Nov.  14  shows  the  presence  of  a  large 
piece  of  shell,  3  cm.  long  by  1^  wide,  two-thirds  of  which 
are  enclosed  in  the  ethmoid  and  the  other  third  projects 
into  the  right  orbit,  after  having  pierced  the  internal  wall. 


Tm.  48. 

Commandant  R.  refused  all  interference ;  moreover,  the 
foreign  body  had  been  well  tolerated  for  sixteen  months. 

From  the  orbito-ocular  point  of  view,  we  note  the  fol- 
lowing— 

(1)  A  fracture  of  the  infero- external  portion  of  the 
left  orbit,  from  which  a  splinter  1  cm.  long  was  extracted 
eight  days  after  the  injury  :  a  depression  of  the  floor 
of  the  orbit  has  resulted,  with  sinking  in  of  the  eyeball 
(traumatic  enophthalmos  from  orbital  fracture). 

(2)  Lesions  of  the  left  eyeball.  This  eye,  normal  ex- 
teriorly and  with  extrinsic  musculature  intact,  presents  on 
the  crystalline  lens  a  slight,  well-defined  opacity,  situated 
above  and  to  the  outer  side.  The  disc  is  a  little  reddened, 
its  contours  blurred  and  ill-defined  (neuritis  and  peri- 
neuritis).    The  macular  region  on  careful  examination  is 


PRESERVATION  OF  THE  EYEBALL         931 

found  to  be  oedematous,  thus  explaining  the  metamor- 
phopsia  of  which  the  patient  complains.  At  the  lower 
part,  near  the  equatorial  region,  is  a  large  patch  of  atrophic 
and  pigmented  choroido-retinitis,  remains  of  rupture  and 
haemorrhage  of  these  deep  membranes. 

L.  E.        V  -  1/10. 

(3)  On  the  right,  we  note  a  proliferating  macular 
choroido-retinitis  surrounded  by  pigment,  causing  a  central 
scotoma  in  the  visual  field  and  lowering  the  acuity  to  1/100 
(Plate  IV,  Fig.  2). 

The  right  eye  shows  slight  external  strabismus,  due  to 
disuse.  There  exists  a  diplopia  in  which  the  false  image 
is  very  dim,  but  extremely  annoying,  especially  when 
looking  downwards  (paralysis  of  the  left  inferior  rectus 
muscle). 

Fracture  of  the  left  orbit ;   traumatic  enophthalmos  ;   total 
detachment  of  the  retina.    (Case  44.) 

G.  Sergeant,  Zouaves,  wounded  July  1,  1916,  in  the  left 
orbital  region,  by  shell  fragment.  Treated  at  St.  M.  and 
at  Ch.     Admitted  July  18,  1916. 

The  projectile  has  caused  a  large  fracture  of  the  superior 
orbital  margin  and  the  external  region  of  the  left  orbit. 
The  superciliary  arch  is  completely  smashed  in  over  the 
external  two -thirds  and  the  gap  in  the  bone  is  prolonged 
to  the  ascending  process  of  the  malar  bone. 

The  upper  eyelid  is  in  a  condition  of  ptosis  owing  to 
paralysis  of  the  levator,  and  also  because  of  the  retraction 
of  the  eyeball. 

The  latter,  in  fact,  is  pushed  back  into  the  orbit,  and 
the  enophthalmos  measures  4  or  5  mm.  No  movement 
is  possible  by  reason  of  the  extreme  relaxation  of  the 
extrinsic  muscles. 

The  pupil  is  dilated  to  the  maximum.  The  anterior 
segment  of  the  eye  is  intact;  ophthalmoscopic  examina- 
tion reveals  total  detachment  of  the  retina,  explaining  the 
hypotony  of  the  eye. 

Vision  equals  0. 

The  enophthalmos  may  be  explained  either  by  the  depres- 
sion of  the  orbital  walls  or  by  the  retraction  of  the  retro- 
bulbar adipose  cushion.  Depression  of  the  walls  is  the  more 
probable  because  n  large  piece  of  shell  was  extracted,  two 


932 


FRACTURES  OF   THE  ORBIT 


days  after  the  injury,  from  behind  the  eye  against  the 
inferior  wall.  Besides,  the  radiogram  shows  tliis  depression 
(Fig.  49). 

Sep.  2,  1916,  section  of  the  four  recti  muscles,  an  attempt 
to  palliate  the  retraction  of  the  globe,  gave  no  result. 

Sep.  11,  restoration  of  the  superciliary  arch  was  attempted 
by  means  of  a  graft  of  costal  cartilage ;    a  piece  six  centi- 


Fig.  49. 

metres  long  was  removed  from  the  rib,  and  at  the  same 
time  a  portion  of  pre-costal  adipose  tissue. 

The  cutaneous  orbital  cicatrix  was  carefully  excised; 
then,  by  splitting  the  subcutaneous  layer  of  tissue,  a  cavity 
was  made,  large  enough  to  contain  the  cartilaginous  and 
fatty  grafts.  Suture  of  the  superficial  layers  by  silk- 
worni  gut. 

Post-operative  progress  entirely  satisfactory;  the  wound 
healed  by  first  intention,  and  a  fortnight  later  the  restora- 


PRESERVATION  OF   THE  EYEBALL          !j-,3 

tion  of  the  superior  wall  of  the  orbit  was  as  successful  as 
possible.  But  as  the  enophthalinos  made  the  region  uiost 
unsightly  the  patient  asked  for  enucleation,  which  was 
done  Sep.  20,  1910,  and  an  artificial  substitute  gave  an 
excellent  result. 

G.  left  Oct.  24,  1910,  completely  recovered. 

A  case   of  post-traumatic   enophthalmos ;     depression   of   the 
external  orbital  wall  and  of  the  inferior  orbital  margin. 

(Case  45.) 

J.  R.,  Mechanic,  aged  twenty-one  years,  living  at  Poitiers, 
was  cycling,  March  10,  1912,  when  he  collided  with  a 
carriage.  R.  was  struck  in  the  right  orbital  region  by  the 
mud-guard ;  the  shock  was  so  violent  that  it  was  broken 
and  the  patient  thrown  to  the  ground.  At  the  hospital 
at  Poitiers,  where  he  was  immediately  taken,  depression 
of  the  root  of  the  nose  and  a  smash  of  the  external  orbital 
margin  were  discovered.  A  large  splinter  of  wood  was 
taken  from  the  temporal  region,  where  it  had  lodged  above 
the  zygomatic  arch ;  one  of  the  nasal  bones  was  eliminated 
through  the  nostril  during  an  attack  of  haemorrhage . 

Suppuration  was  overcome  with  difficulty,  and  it  was 
only  after  eighty  eight  days  of  treatment  that  cicatrisation 
could  be  obtained.  R.  then  stated  that  he  saw  double, 
and  as  this  constant  diplopia  rendered  all  work  impossible 
he  came  to  consult  us  on  Oct.  17,  1912. 

The  patient  bears  numerous  scars  situated  about  the 
internal  canthus  of  the  right  eye  and  on  the  lower  eyelid, 
which  is  ectropionized ;  there  is  ptosis  due  to  the.  enoph- 
thalmos ;  it  is  not  accompanied  by  any  lesion  of  the  levator, 
which  functions  perfectly,  as  does  also  the  superior  rectus. 

The  eyeball  is  very  markedly  retracted,  estimated  at 
5  mm.  by  comparison  with  the  sound  eye.  This  sinking  in 
of  the  globe  does  not  vary  with  the  position  of  the  head, 
and  is  riot  modified  by  effort.  The  eye,  which  is  not  su}^- 
ported  by  the  external  wall,  has  slipped  outwards  upon 
the  orbital  floor  and  is  plainly  deviated  to  the  outer  side 
and  below.  Hence  the  patient  complains  of  crossed 
diplopia  in  every  direction.  The  images  are  20  cm.  apart 
when  looking  ahead ;  this  separation  is  much  increased 
(80  cm.)  when  the  candle  is  moved  to  the  nasal  side;  it  is 
slightly  less  on  the  temporal  side.     The  patient  complains 


934  FRACTURES  OF  THE  ORBIT 

that  in  every  direction  the  images  are  on  a  different  level. 
The  visual  field  is,  however,  normal ;  acuity  =  1 .  Exami- 
nation by  oblique  illumination  shows  that  the  cornea, 
quite  transparent,  has  been  entirely  spared  by  the  injury. 
The  anterior  chamber  is  of  normal  depth,  the  pupil 
presents  nothing  pathological,  the  iris  reacts  well  to 
light  and  to  accommodation.  No  trouble  can  be  found  in 
the  transparent  media,  and  the  ophthalmoscope  reveals 
nothing  worthy  of  being  put  on  record. 

The  left  eye  is  quite  untouched,  the  injuries  not  extend- 
ing beyond  the  bridge  of  the  nose;  this  eye  is  emmetropic 
and  possesses  acuity  =  1. 

In  short,  this  was  a  traumatic  enophthalmos  due  to 
depression  of  the  external  orbital  wall,  and  perhaps  also,  in 
part,  to  the  effects  of  prolonged  suppuration  of  the  tissues 
of  the  orbit. 

By  tenotomy  of  the  four  recti  muscles  the  enophthalmos 
was  considerably  ameliorated. 


Symptoms  and  Diagnosis 

In  the  cases  in  which  enophthalmos  is  due  to  depres- 
sion of  the  orbital  walls  there  are  always  signs  and 
traces,  more  or  less  old,  of  severe  traumatism  of  the 
orbit.  At  the  time  of  the  accident  there  is  abundant 
epistaxis  and  sub-conjunctival  ecchymosis ;  profuse 
retrobulbar  haemorrhage  may  take  place  and  bring 
about  in  the  early  stages  an  exophthalmos,  which  gives 
place  later  to  enophthalmos. 

During  the  whole  of  this  early  period  the  patient 
opens  the  eyes  with  difficulty,  and  it  is  only  when  the 
disappearance  of  palpebral  swelling  allows  the  ready 
separation  of  the  eyelids  that  the  more  or  less  pro- 
nounced sinking  in  of  the  eyeball  is  noticed. 

Usually  it  is  about  a  fortnight  before  the  patient 
opens  his  eyes ;  he  habitually  remarks  in  the  first  place 
that  he  sees  double ;  this  is  the  rule  when  visual 
acuity  is  good.  It  is  often  on  account  of  the  diplopia 
that  the  patient,  till  then  in  the  hands  of  the  general 
surgeon,  seeks  the  advice  of  the  ophthalmic  specialist. 

The  latter  immediately  notices  two  principal  symp- 


PRESERVATION  OF  THE  EYEBALL         935 

toms,  viz.,  ptosis  and  restriction  in  the  ocular  move- 
ments. The  ptosis  is  generally  due,  not  to  paralysis 
of  the  levator,  but  to  the  fact  that  the  upper  eyelid 
has  partly  lost  its  natural  support,  which  is  the  eye  ;  it 
sinks  in  with  it,  and  is  lowered  because  it  is  sunk  in, 
and  in  the  same  proportion. 

In  one  of  our  cases,  however,  we  noticed  paralysis 
of  the  elevator,  consecutive  to  traumatism  of  the 
supra-orbital  region,  which  had  directly  implicated  the 
levator  palpebrse. 

The  eye  is  usually  well  fixed  in  its  new  position,  and 
it  is  only  in  exceptional  cases  that  intermittent  enoph- 
thalmos  and  exophthalmos  have  been  found ;  Jean 
Terson  has  reported  three  such  cases. 

The  visual  field  is  normal,  the  range  of  outlook 
restricted  by  the  difficulty  of  excursion  of  the  muscles ; 
usually  the  media  of  the  eye  and  the  deep  membranes 
are  healthy.  We  shall  not  spend  more  time  upon  the 
symptomatology,  which  will  be  found  in  all  the  text- 
books, as  well  as  in  the  thesis  of  Dr.  Daulnoy  (Nancy, 
1898-9),  which  is  well  suppHed  with  references.  We 
must  limit  ourselves  to  bringing  forward  here  the 
symptoms  presented  by  the  cases  we  have  reported 
above. 

Our  patient  in  Case  43  was  a  typical  example  of 
traumatic  enophthalmos ;  the  enophthalmic  eye  pre- 
sented a  slight  opacity  of  the  lens  and  papillary  inflam- 
matory troubles,  but,  the  extrinsic  musculature  being 
intact,  the  diplopia  complained  of  by  the  patient  was 
the  result  of  lowering  of  the  eye  by  depression  of  the 
floor  of  the  orbit. 

In  the  same  manner  in  Case  44  the  radiogram  shows 
a  very  clear  depression  of  the  inferior  orbital  waU ; 
in  this  case,  further,  the  eye,  lessened  in  tension,  was 
itself  diminished  in  volume  and  had  lost  all  acuity  by 
reason  of  total  detachment  of  the  retina. 

In  Case  45,  which  was  an  example  of  grave  trauma- 
tism worthy  to  be  compared  with  traumatism  of  war,  the 
enophthalmos,  again  due  to  bony  depression,  was  very 
marked  (5mm.) ;   the  subject  had  good  visual  acuity, 


936  FRACTURES  OF   THE  ORBIT 

so  good  that  he  complained  of  a  very  tiresome  diplopia 
some  months  after  the  injury.  In  his  case  a  tenotomy 
of  the  four  recti  muscles,  following  Darier's  procedure 
in  similar  cases,  brought  about  great  improvement. 

Our  other  cases  differ  from  the  preceding  in  that 
trophic  disorders  were  the  cause  of  the  enophthalmos. 
In  one  of  the  patients  (Case  41)  we  had  to  do  with  a 
lesion  of  the  frontal  region  due  to  an  extra-orbital 
foreign  body,  which  had  perhaps  caused  a  fracture  of  the 
orbit,  irradiated  to  the  apex,  and  which  had  implicated 
the  motor  and  sensory  nerves ;  the  eye  had  preserved 
a  good  exterior  appearance,  but  showed  extensive 
detachment  of  the  retina. 

Finally,  our  Case  42  is  a  case  of  enophthalmos  from 
nerve  lesions  and  trophic  troubles  characterised  by  the 
folloAving  signs.  The  patient  had  a  wound  in  the 
supra-orbital  region  ;  the  visual  acuity  of  the  enoph- 
thalmic  eye  was  7/10.  and  there  was  paralysis  of  the 
superior  rectus,  the  external  rectus  and  the  inferior 
oblique,  entailing  a  very  distressing  diplopia.  Probably 
the  third  and  sixth  nerves  had  been  injured  in  the 
sphenoidal  fissure,  and  at  the  same  time  the  sympathetic 
filaments,  emanating  from  the  carotid  plexus,  had  been 
torn  at  this  level.  The  trophic  disturbances  were  con- 
secutive to  this  lesion.  These  two  cases  are  types  of 
true  enophthalmos,  as  is  also  Case  40. 

Diagnosis. — We  do  not  think  we  need  linger  over 
the  diagnosis  of  enophthalmos. 

The  appearance  of  the  patient  is  usually  character- 
istic and  the  diagnosis  is  made  from  a  distance,  at  the 
first  glance.  In  doubtful  cases,  at  the  onset  of  the 
affection,  we  may  have  recourse  to  the  orthometers  and 
ophthal meters,  recommended  by  HasnEr,  Waknam, 
Zehender,  CocciiTs,  and  Maklakow  ;  but  it  will  be 
simpler  and  more  practical  to  use  for  the  same  purpose 
the  ophthalmometer  of  Javal.  The  eyes  must  be 
placed  in  a  plane  exactly  parallel  with  the  plane  of 
the  instrument,  and,  reflecting  the  "mires"  of  the 
instrument  successively  from  each  cornea,  one  notes 
how  many  millimetres  it  is  necessary  to  advance  the 


PRESERVATION  OF   THE  EYEBALL         0:37 

instrument  to  focus  it  when  examining  the  enophthalmic 
eye ;  this  procedure  is  quite  satisfactory  and  enables 
one  to  dispense  with  special  apparatus. 

We  shall  say  nothing  here  concerning  prognosis 
which  is  not  familiar ;  the  affection  remains  stationary 
when  it  is  left'  to  itself,  and  treatment  yields  but  very 
mediocre  results.  We  should  here,  however,  mention 
the  good  results  quoted  by  some  writers,  from  electri- 
cal treatment  by  the  continuous  current ;  also  tenotomy 
of  the  four  recti  muscles,  advocated  by  Darier. 

This  gave  us  a  favourable  result  in  one  of  our  cases 
(Case  45). 


CHAPTER  V 

FRACTURES  OF  THE  ORBIT 
WITH  DESTRUCTION  OF  THE  EYEBALL 

The  destruction  of  the  eyeball  may  occur  either  with 
the  presence  of  a  foreign  body  or  without  the  foreign 
body  remaining  in  the  orbit.  The  immediate  disorders 
are  the  same ;  but  in  the  second  category  of  cases,  the 
complications  which  result  from  the  presence  of  the 
foreign  body,  come  in  to  darken  the  picture. 

Most  frequently  pieces  of  shell  smashing  in  the 
external  wall  of  the  orbit,  crushing  the  eye,  and 
coming  to  rest  near  it  or  in  the  neighbouring  cavities 
are  the  objects  of  interest  in  the  cases  of  the  second 
category.  Bullets  traverse  the  orbit  and  fracture  it, 
but  escape  after  having  destroyed  the  eye  and  traversed 
the  bony  mass  of  the  face. 

We  could  report  a  large  number  6i  cases  of  this  kind, 
but  shall  limit  ourselves  to  the  four  following. 

Fracture   of  left  orbit ;    rupture   of  eyeball ;    arterio-venous 
aneurism  of  the  left  internal  carotid.    (Case  46.) 

A.,  Sergeant,  Infantry,  was  wounded  April  14,  1915, 
by  a  I ifie- bullet  at  M.  Treated  for  ten  days  at  Ch.,  he 
came  to  us  April  27. 

The  rifle-bullet  entered  the  left  lateral  part  of  the  neck 
along  the  posterior  border  of  the  sterno-cleido-mastoid, 
three  fingers'  breadth  below  the  inferior  extremity  of  the 
mastoid  process. 

Following  a  course  from  below  upwards  and  from  behind 
forwards  it  came  out  at  the  level  of  the  floor  of  the  left 
orbit. 

The  left  eyelid  is  totally  destroyed ;  the  aperture  of  exit 
is  found  almost  in  the  inferior  conjunctival  cul-de-sac. 
The  projectile  has  caused  the  rupture  of  the  eyeball,  which 

938 


DESTRUCTION  OF  THE  EYEBALL 


939 


is  now  reduced  to  a  small  shapeless  stump,  inflamed  and 
painful. 

The  radiogram,  whilst  enabling  us  to  determine  the 
absence  of  a  foreign  body,  shows  a  depression  of  the 
anterior  portion  of  the  floor  and  of  the  orbital  margin. 
R.  E.  normal. 

Enucleation  of  the  left  eye  was  performed  April  30. 
During  the  next  few  days,  A.  drew  6ur  attention  to  a 
continuous  buzzing  in  the  ear,  and  left  migraine.     This 


Fig.  50. 


whistling,  synchronous  with  the  cardiac  beat,  was  exas- 
perating, causing  atrocious  headaches,  and  entirely  pre- 
venting sleep.     Extreme  vaso-constriction  of  the  face. 

Dr.  Lacouture,  called  in  consultation,  concluded  from 
his  examination  that  there  was  an  arterio- venous  aneurism 
seated  on  the  left  internal  carotid.  Artery  and  jugular 
vein  must  have  been  injured  by  the  bullet  in  its  course. 

May  5,  1915,  ligature  of  the  internal  carotid.  Post- 
operative progress  most  satisfactory;  disappearance  of  all 
the  symptoms;  no  complication  has  occurred  since  this 
intervention. 

A  blepharoplasty  of  the  lower  eyelid  was  done  July  15, 
1915,  by  means  of  a  fronto-parietal  flap.  This  operation 
allowed  the  patient  to  wear  an  artificial  eye  easily. 

He  left  hospital  June  17,  1915,  completely  recovered. 


040  FRACTURES  OF  THE  ORBIT 

Fracture  of  left  orbit ;    rupture  of  eyeball.    (Case  47.) 

J.  S.,  Infantry,  rifle-bullet  in  the  face,  Aug.  28,  1914,  at 
R.  Made  a  prisoner,  he  was  released  June  25,  1915,  and. 
was  admitted  Aug.  4,  the  same  year. 

Condition. — The  bullet  penetrated  the  right  ala  of  the 
nose ;  after  having  traversed  the  nasal  fossae  from  side  to 
side  it  has  fractured  the  left  internal  orbital  wall  a  little 
above  the  lacrymal  sac ;  continuing  its  course,  it  has 
ruptured  the  globe  and  emerged  from  the  fronto-temporal 
region  at  the  supero-external  angle  of  the  orbit. 

At  this  point  is  to  be  seen  a  deep  depression  of  the  bone, 
tlie  size  of  a  crown-piece,  produced  by  the  fracture  of  the 
ascending  process  of  the  malar  bone  and  the  external  process 
of  the  frontal  bone.  The  cutaneous  cicatrix  extends  to 
the  external  third  of  the  eyebrow,  which  is  much  drawn 
downwards. 

There  is  ptosis  of  the  upper  eyelid  and  symblepharon 
over  the  external  third  of  the  two  eyelids ;  the  lower 
eyelid  is  torn  in  the  neighbourhood  of  the  lacrymal  sac, 
and  is  adherent  below,  in  a  vicious  position. 

The  eyeball,  entirely  destroyed,  was  enucleated  eight 
days  after  the  injury. 

The  right  eye  is  normal,  V  ^  10/10. 

Aug.  12,  1915,  surgical  intervention.  In  the  first  stage, 
the  two  eyelids  were  freed  (section  of  the  symblepharon) ; 
next,  after  freshening  the  inferior  and  internal  palpebral 
border,  it  was  drawn  upwards,  restoring  the  canthus.  After 
dissection  of  the  skin  about  the  external  orbital  cicatrix, 
the  very  unsightly  depression  of .  the  bone  was  filled  up 
by  means  of  adipose  tissue  taken  from  the  left  buttock. 
Sutures  and  dressings.  Post-operative  conditions  excel- 
lent ;  the  adipose  graft  took  by  first  intention.  In  spite 
of  this  operation  the  conjunctival  cavity  remained  atypical, 
very  narrow,  permitting,  however,  the  use  of  an  artificial 
eye. 

S.  left  hospital  Sep.  21,  1915. 

Fracture  of  the  right  orbit ;  rupture  of  right  eyeball ;  traumatic 
choroido-retinitis  and  optic  atrophy,  L.  E.    (Case  48.) 

M.  P.,  Infantry,  wounded  Jan.  14,  1916,  by  rifle-bullet. 
Taken  to  Ch.  Jan.  15,  he  came  to  us  Feb.  8,  1916. 


DESTRUCTION  OF   THE   EYEBALL  !)41 

Condition. — P.  was  struck  by  a  rifle-bullet  from  a  dis- 
tance of  about  150  metres.  The  projectile  traversed  the 
face  from  left  to  right,  obliquely  upwards  and  outwards ; 
it  penetrated  at  the  union  of  the  malar  with  the  zygomatic 
arch,  emerging  by  the  su])ero-extcrnal  angle  of  the  right 
orbit,  near  the  outer  extremity  of  the  eyebrow,  traversing 
this  cavity  throughout  its  width,  and  causing  an  extensive 
fracture  of  the  external  wall,  which  can  be  felt  depressed. 

The  right  eye,  ruptured  and  only  existing  in  the  form  of 
debris,  had  been  enucleated  at  once.  The  upper  eyelid  is 
destroyed  in  its  external  two-thirds;  and  surgical  inter- 
ference in  two  stages,  Fob.  20  and  Mar.  12,  blepharoplasty 
by  transplantation  (pedicle)  and  Snellen's  sutures,  permitted 
the  wearing  of  an  artificial  eye. 

On  the  left  side  visual  troubles  appeared  immediately 
after  the  injury.  P.  declares  that  on  arrival  at  Ch.  he 
found  a  very  great  diminution  of  visual  acuity  in  that  eye ; 
it  improved  in  the  period  immediately  following,  and  since 
then  it  has  remained  stationary. 

L.  E.         V  =  1/10  good. 

The  globe  is  normal  exteriorly.  The  pupillary  reflexes 
are  good ;  the  transparent  media  clear. 

In  the  macular  region,  especially  marked  below  and  to 
the  inner  side,  there  is  atrophic  and  pigmented  choroido- 
retinitis,  secondary  to  a  haemorrhage  of  the  membranes 
and  causing  a  slight  ascending  atrophy  of  the  optic  nerve 
(concussion  lesions).  The  disc  is,  in  fact,  decoloured, 
whitish,  with  contours  somewhat  pigmented. 

Discharged  July  7,  1916,  in  the  same  condition. 

Fracture  of  right  orbit ;    rupture  of  eyeball.    (Case  49.) 

E.  S.,  Infantry,  wounded  Oct.  6,  1915,  by  grenade  frag- 
ment.    From  Tarbes,  he  arrived  Dec.  10,  1915. 

Condition. — Cicatrix  about  3  cm.  long,  direction  vertical, 
in  right  superior  orbital  region.  It  starts  from  the  anterior 
frontal  region,  2  cm.  above  the  eyebrow  and  two  fingers 
breadth  from  the  root  of  the  nose;  the  superior  orbital 
margin  is  fractured  at  the  junction  of  the  inner  third  and 
the  outer  two-thirds.  A  deep  notch  of  the  underlying 
bony  wall  can  be  felt. 

The   upper    eyelid   is   divided   and   in   a   condition   of 


942  FRACTURES  OF  THE  ORBIT 

cicatricial  ectropion;  the  palpebral  borders  are  adherent 
to  the  depressed  bone. 

The  ruptured  eyeball  was  enucleated  two  days  after  the 
injury.     The  left  eye  is  normal,  V  =  10/10. 

Jan.  10,  1916,  restoration  of  the  upper  eyelid  was  pro- 
ceeded with.  The  cicatricial  tissue  was  undermined,  and 
after  refreshing  the  two  ciliary  borders  the  palpebral 
portions  were  sewn  together.  Snellen's  sutures  were  used 
to  deepen  the  superior  conjunctival  cul-de-sac.  An  arti- 
ficial eye  was  given. 

S.  left  hospital  Feb.  6,  1916,  completely  recovered. 


These  four  cases  all  present  remarkable  peculiarities. 

The  first  concerns  a  patient  who,  in  addition  to  his 
serious  orbital  lesion,  had  an  arterio -venous  aneurism 
of  the  internal  carotid  and  the  jugular;  this  aneu- 
rism was  cured  by  ligature  of  the  internal  carotid 
performed  by  Dr.  Lacouture  ;  it  was  afterwards 
possible,  by  means  of  a  blepharoplasty,  to  restore  the 
eyelids  in  such  a  manner  as  to  permit  the  wearing  of 
an  artificial  eye. 

The  second  case  furnished  us  with  the  opportunity 
for  practising  with  success  our  first  adipose  graft,  per- 
mitting us  to  repair  the  large  loss  of  substance  resulting 
from  the  destruction  by  a  bullet  of  the  external  process 
of  the  frontal  and  of  the  malar  bone. 

The  third  is  a  subject  in  whom,  besides  the  rupture 
of  the  right  eye,  we  noted  in  the  left  eye  macular 
concussion  lesions  already  fully  described  (see  p.  896). 

The  fourth  case  is  remarkable  for  the  presence  of  an 
important  fracture  of  the  whole  of  the  superior  margin 
of  the  orbit,  coupled  with  an  extensive  destruction  of 
the  upper  eyelid.  A  Snellen's  suture  above  and  an 
appropriate  blepharoplasty  allowed  us  to  place  this 
subject  under  conditions  for  an  aesthetic  prothesis. 

In  all  these  cases,  as  well  as  in  those  in  which  the  eye 
has  been  struck  by  a  bullet,  the  organ  was  destroyed 
in  such  a  manner  that  only  debris  remained,  and  it  is 
impossible  to  give  an  account  of  the  mechanism  which 
has  been  responsible  for  the  rupture. 


DESTRUCTION  OF  THE  EYEBALL  943 

Shrapnel  balls  or  shell  fragments  reduce  the  eye  to 
the  condition  of  a  stump,  but  do  not  like  bullets  tear 
it  in  pieces ;  one  finds  still  in  the  orbit  a  more  or  less 
painful  stump,  with  a  foreign  body  in  its  vicinity.  The 
injury  to  the  eyeball  is  not  less  serious ;  on  the  con- 
trary, this  shrivelled  and  torn  globe  retains  in  its 
interior  the  inflamed  uveal  tract,  which  is  brought  in 
contact  with  the  infected  orbital  cavity  by  means  of  the 
ruptures  in  the  sclerotic,  and  thus  serious  irritation, 
may  result,  implicating  the  other  eye. 

When  the  eye  has  been  torn  to  pieces  by  a  ball,  or 
opened  by  the  explosion  of  a  grenade,  usually  the  uveal 
tract  begins  to  suppurate,  and  suppuration  is  the 
enemy,  the  antagonist,  of  sympathetic  ophthalmia ; 
the  choroid  is  eliminated  and  very  soon  nothing 
remains  of  the  contents  of  the  burst  ocular  envelope. 
On  the  other  hand,  when  there  has  been  attrition  and 
rupture  of  the  eye  by  a  shell -fragment  the  withered 
eye  shrivels  up,  keeping  in  its  interior  inflamed  uveal 
tissue ;  the  painful  stump  remains,  with  all  its  danger. 
This  is  demonstrated  by  the  following  cases. 

Wound  of  the  left  temporo-orbital  region ;  fracture  of  the  ex- 
ternal wall  of  the  orbit ;  rupture  of  the  eye\^all ;  persistence 
of  foreign  body  in  the  orbit.    (Case  50.) 

C.  D.  Infantry,  wounded  in  Champagne  by  ^hell  frag- 
ments ;  after  twelve  days  reached  Bordeaux,  April  12, 1916. 

Condition. — On  his  arrival,  there  was  a  large  wound, 
extending  from  about  2  cms.  from  the  meatus  of  the  left 
ear  to  the  external  third  of  the  left  lower  eyelid.  There 
was  a  comminuted  fracture  of  the  zygomatic  process  and 
of  the  malar  bone. 

The  inferior  orbital  margin  is  also  the  seat  of  a  notch 
caused  by  the  projectile. 

The  left  lower  eyelid  is  pulled  down  on  its  outer  side. 
The  eyeball  persists,  at  the  bottom  of  the  orbital  cavity, 
in  the  form  of  a  small  inflamed  and  painful  stump. 

Radiography  shows  the  existence  of  a  large  shell  frag- 
ment lodged  in  the  orbit  behind  the  stump  (Fig.  51). 

May  18,  1916,  enucleation  of  the  eyeball  and  extraction 
of  the  foreign  body.    We  then  proceeded  to  restore  the 


944 


FRACTURES  OF   THE  ORBIT 


outer  third  of  the  destroyed  lower  eyelid  by  transplantation 
of  a  flap  taken  from  the  external  orbital  region. 
Cicatrisation  by  first  intention. 

R.  E.  intact.         V  =  10/10. 

The  prothesis  has  been  specially  moulded ;  after  pro- 
gressive dilatation,  the  wearing  of  an  artificial  eye  of 
almost  normal  size  has  been  tolerated. 


Fid.  r,]. 


Fracture  of  the  right  orbit ;    rupture  of  the  eyeball ;    shrapnel 
ball  at  the  apex  of  the  orbit.     (Case  51.) 

A.  C,  Sergeant,  Infantry,  wounded  at  A.,  Aug.  24,  1914. 
From  Troyes,  via  Casteljaloux,  he  arrived  at  Bordeaux 
Oct.  20,  1914. 

Condition. — In  the  external  orbital  region  is  seen  a 
depressed  cicatrix,  with  starred  margins,  probably  the 
orifice  of  entry  of  the  ])r()jectile.  Beneath  can  be  felt  the 
fractured  ascending  ])rocess  of  the  malar  bone. 

Two  months  after  the  injury  there  was  still  voluminous 
chemosis  below,  evidence  of  an  intra-orbital  effusion  of 
blood,  absorbed,  with  inflammatory  sequelae. 

The  eyeball  is  reduced  to  a  small  stump  covered  by 
conjunctiva,  clearly  felt  on  palpation. 


DESTRUCTION  OF   THE  EYEBALL 


945 


Since  the  injury  C.  has  experienced  sharp  pains  in  the 
right  supra-orbital  region. 

Radiography  shov/s  the  presence  of  a  shrapnel  ball, 
lodged  in  the  right  orbit,  towards  the  apex  (Fig.  52). 

Oct.  28,  1914,  we  proceeded  to  enucleate  the  stunij). 
Orbital  exploration  allowed  us  to  mark  the  exact  location 
of  the  projectile,  which  was  extracted  by  the  gouge  with 
difficulty. 

Post -operative  progress  excellent. 

C.  left  hospital  Nov.  12,  after  the  fitting  of  an  artificial 
eye.     The  left  eye  was  normal. 

L.  E.,  with  -f  0-50  D  sph.,V  -=  9/10. 


Fig.  52. 


Still  more  curious  is  the  following  case,  in  which  we 
found  a  foreign  body  by  the  side  of  the  optic  nerve, 
irritating  it  to  the  point  of  determining,  not  attenuated 
sympathetic  phenomena,  but  a  true  ophthalmia. 


Foreign  body  irritating  the  optic  nerve  ;    sympathetic 
ophthalmia.    (Case  52.) 

A.  T.,  Infantry,  wounded  Oct.  11,  1915,  at  P.     Admitted 
Oct.  24  of  the  same  year. 


946  FRACTURES  OF  THE  ORBIT 

Symptoms  on  Admission. — T.  had  a  perforating  wound 
of  the  eyeball  from  a  shell  wound.  The  eye  was  in  a 
condition  of  complete  panophthalmitis  at  the  time  of  our 
first  examination.  The  left  eye  was  normal,  V  =  10/10. 
Evisceration  of  the  globe  was  performed  Oct.  28,  1915, 
with  all  possible  care  to  leave  no  trace  of  the  uveal  tract 
in  the  scleral  envelope. 

Nov.  7.  T.  complained,  for  the  first  time,  of  a  sensa- 
tion of  mistiness  and  diminution  of  vision  in  his  left  eye. 
Ophthalmoscopic  examination  revealed  the  existence  of  a 
well-marked  optic  neuritis;  acuity  then  equalled  1/10. 

The  next  day  enucleation  of  the  stump  on  the  right  side 
was  performed.  Dissection  of  this  stump  showed  that  a 
tiny  portion  of  shell  was  in  the  substance  of  the  sclerotic, 
in  contact  with  the  optic  nerve.  Intensive  mercurial  treatment 
was  commenced  (intravenous  injection  of  cyanide,  friction 
with  mercurial  ointment,  counter-irritation  atropine). 

The  neuritis  improved  slowly  and  progressively,  so  that 
on  May  30,  1916,  the  visual  acuity,  with  +  1*25  D  sph. 
again  equalled  10/10 ;  the  disc  presented  a  normal  aspect, 
its  scleral  borders  quite  clear. 

He  was  discharged  May  27,  1916,  completely  recovered. 

We  now  arrive  at  a  variety  of  fractures  of  the  orbit 
of  the  greatest  interest,  those  which  are  accompanied 
by  destruction  of  the  eyeball  with  implication  of  the 
neighbouring  cavities. 


Fractures  Implicating  the  Neighbouring  Cavities 

We  shall  group  the  cases  of  this  kind  into  three  series, 
according  as  the  orbital  fractures  involve  :  (a)  the 
maxillary  antrum ;  (6)  the  frontal  sinus ;  (c)  the  cere- 
bral cavity. 

It  is  evident  that  these  three  varieties  present 
different  degrees  of  gravity  and  characteristic  symp- 
toms, but  they  have  everything  in  common  from  the 
setiological  point  of  view.  It  is  almost  always  pieces 
of  shell,  fragments  of  grenades,  rarely  shrapnel  balls, 
very  exceptionally  bullets,  which  bring  about  the  great 
facial  and  cranial  derangements.     The  bullet  is  a  narrow^ 


DESTRUCTION  OF   THE  EYEBALL 


947 


projectile,  involving  disorders  at  a  distance  by  vibra- 
tion or  oscillation  of  the  tissues.  The  pieces  of  shell 
shake  the  neighbouring  regions  less,  but  they  break 
the  bones,  drive  in  the  walls,  and  cause  the  orbital 
cavity  to  communicate  freely  with  the  cavities  which 
surround  it.     By  way  of  a  specimen  we  reproduce  here 


Fig.  53. — Smash  of  the  orbital  region  by  a  large  piece  of  shell. 


a  photograph  (Fig.  53)  portraying  the  lesions  produced 
in  such  a  case  in  the  orbital  region ;  and  two  radio- 
grams (Figs.  54  and  55),  which  represent  two  good 
examples  of  fracture  with  loss  of  substance. 

Of  these  two  radiograms,  one  (Fig.  54)  refers  to  a 
subject  in  whom  the  loss  of  substance  has  been  repaired 
by  a  cartilaginous  graft ;  it  is  drawn  from  a  very  correct 
proof.     The  other  (Fig.  55)  refers  to  Case  64  (p.  964). 


J)4R 


FRACTURED  OF   THE  ORBIT 


One  can  see  plainly  there  the  crushing  in  of  the  external 
wall  of  the  orbit.  We  give  these  two  types  of  fracture 
by  way  of  example ;  we  have  many  others  in  our 
collection. 

The  attrition  which  results  from  such  traumatism 
is  quickly  followed  by  suppuration,  and  thus  is 
developed  sinusitis,  interminable  if  not  remedied,  or 


Fig.  54.— Fracture  and  loss  of  substance  of  the  left  external 
orbital  region, 

rapidly  fatal  cranial  disorders,  if  efficacious  interference 
is  not  quickly  brought  to  bear. 

It  is  these  cases  of  fracture  of  the  orbit  with  opening 
of  the  sinus  and  destruction  of  the  orbital  margins 
which  need  the  plastic  operations  with  grafts  of  which 
we  shall  speak  later. 


(a)  Maxillary  Antrum 

We  could  multiply  cases  here,  but  as  in  our  other 
groups  we  shall  be  content  with  choosing  a  few  out  of 
our  collection. 


DESTRUCTION  OF  THE  EYEBALL 


Md 


Fracture  of  the  floor  of  the  left  orbit ;    crushing  of  eyeball. 

(Case  53.) 

L.  O.,  Sergeant,  Infantry,  wounded  Aug.  28,   191^,  at 
B.,  by  shell.     No  loss  of  consciousness.     Dressed  the  same 


Fig.  55. — Fracture  of  the  supero-external  region  of  the  left  orbit. 

evening,  he  went  first  to  Libourne,  thence  to  Bordeaux, 
admitted  Oct.  7. 

Examination. — There  is  an  extensive  wound  of  the  left 
infero-external  orbital  region;  the  divided  lower  eyelid 
is  wanting  in  its  external  two-thirds;  in  this  region  the 


950 


FRACTURES  OF  THE  ORBIT 


integuments  are  absent  and  leave  the  maxilla  bare ;  its  vault 
and  anterior  wall  are  smashed  in.  The  outer  part  of  the 
upper  eyelid  is  equally  destroyed  as  far  as  the  outer  ex- 
tremity of  the  eyebrow,  and  is  adherent  to  the  underlying 
bone. 

The  patient  discharged  large  quantities  of  pus  due  to 
well-marked  sinusitis,  from  the  wound  and  from  the  nose, 
and  on  Sep.  13  expectorated  a  large  splinter,  which  came 
from  the  anterior  wall  of  the  sinus. 

The  left  eyeball  presents  a  rupture  of  the  sclerotic  at  its 
lower  part,  on  the  side  of  the  orbital  fracture.     Reduced 


Fig.  56. 


to  the  condition  of  a  stump,  its  enucleation  was  judged  to 
be  necessary,  and  this  was  done  Oct.  14. 

Upon  the  radiogram  we  see  very  clearly  the  depression 
of  the  anterior  wall  of  the  antrum  and  the  crushing  in  of 
the  floor  of  the  orbit.  There  is  a  small  foreign  body  in  the 
sinus.  Some  small  bone  fragments  are  situated  near  the 
hole  in  the  maxilla ;  one,  larger,  is  in  th«  pharyngeal  region, 
explaining  the  difficulty  in  chewing  and  swallowing. 

Oct.  14,  besides  enucleation,  we  proceeded  to  repair  the 
anterior  wall  of  the  antrum  and  the  eyelids ;  the  drainage 
of  the  antrum  was  afterwards  effected,  after  cleaning  up 
with  a  curette. 

In  the  second  stage,  blepharoplasty  of  the  two  eyelids, 


DESTRUCTION  OF   THE  EYEBALL  951 

by    transplantation    with    a   pedicle.     The   result    of    the 
operations  was  most  satisfactory. 

Fracture  of  the  left  orbit  and  of  the  left  maxillary  sinus  ; 
rupture  of  the  left  eyeball.    (Case  54.) 

E.  C,  Infantry,  wounded  Feb.  25,  1916,  by  a  grenade 
which  burst  one  metre  from  him.  He  was  immediatel}" 
trephined  in  a  field  hospital.  He  stayed  twelve  days  at 
C,  and  reached  us  March  27,  1916. 

Examination. — The  projectile  had  penetrated  the  left  max- 
illarj^  antrum,  and  after  having  traversed  the  left  orbit 
from  side  to  side  emerged  from  the  fronto-parietal  region 
of  the  same  side. 

There  is  a  large  wound  of  the  fronto-parietal  region,  in  a 
fair  way  to  cicatrisation. 

At  the  anterior  portion  of  the  antrum  is  seen  an  irregular 
wound  (aperture  of  entr})-  of  the  shell  fragment),  which  is 
freely  suppurating.  The  ruptured  left  eye  remains  in  the 
form  of  a  small  stump  at  the  bottom  of  the  conjunctival 
cavity. 

Radiography  shows  a  small  projectile  situated  in  the 
maxillary  sinus;  also  two  or  three  splinters,  the  cause  of 
the  prolonged  suppuration  of  the  wound.  The  inferior 
orbital  margin  and  the  floor  of  the  orbit  have  both  been 
fractured. 

In  the  frontal  bone  is  an  extensive  loss  of  bone  sub- 
stance, resulting  from  the  trephining.  A  small  shell 
fragment  remains  at  the  edge  of  the  bony  orifice. 

April  7,  the  stump  was  enucleated ;  next,  the  maxillary 
antrum  was  carefully  curetted;  this  permitted  of  tlie 
extraction  of  the  shell  fragment,  the  splinters  mentioned 
above,  and  some  fragments  of  calcareous  stone. 

June  8,  1916,  maxillary  fistula  was  cicatrised. 

The  orbital  cavity,  although  reduced  in  volume  by  the 
lacerations  of  the  conjunctival  mucous  membrane,  allows 
the  wearing  of  an  artificial  eye. 

R.  E.  intact.         V  =  10/10. 

Fracture  of  right  orbit  and  frontal  sinus ;  destruction  of  the 
eyelids  and  of  the  right  eyeball ;  voluminous  foreign  body 
in  the  left  maxillary  antrum.     (Case  55.) 

E.  M.,  Infantry,   wounded  Feb.   15,  at  M.     Immediate 


952  FRACTURES  OF   THE  ORBIT 

loss  of  consciousness;  he  was  transported  to  Ch.,  where 
the  right  eye,  reduced  to  a  pulp,  was  enucleated.  Admitted 
Feb.  25. 

Examination. — This  soldier  has  been  struck  in  the  right 
orbito-ocular  region  by  several  portions  of  shell,  which  have 
caused  the  following  injuries — 

(1)  Fracture  of  the  frontal  bone,  and  wide  opening  up 
of  the  frontal  sinus,  which  was  freely  suppurating  at  the 
time  of  our  examination. 

(2)  Fracture  of  the  superior  orbital  margin  at  its  outer 
end.  The  right  eyelid  has  been  torn  and  partly  destroyed 
at  this  point. 

(3)  Laceration  of  the  lower  eyelid,  which,  owing  to 
oedema,  assumes  the  shape  of  an  inflated  bag. 

(4)  Rupture  of  the  right  eyeball  (enucleated),  and 
fracture  of  the  floor  of  the  orbit,  easily  felt  on  palpation 
through  the  conjunctival  sac. 

The  left  eye  is  intact;  its  visual  acuity  equals  10/10. 
Radiography  shows  the  presence,  (1)  of  a  small  shell  frag- 
ment in  the  right  orbit;  (2)  of  another  somewhat  larger 
in  the  left  nasal  cavity;  (3)  of  a  third,  very  large,  measur- 
ing 2  cm.  long  by  1  broad,  with  irregular  contour,  lodged 
in  the  left  maxillary  sinus. 

Penetrating  at  the  level  of  the  right  orbit  it  has  there- 
fore crossed  the  nasal  fossae  from  side  to  side  and  fractured 
the  right  antrum. 

March  1.  After  opening  the  anterior  surface  of  the  left 
sinus  the  projectile  was  extracted.  Drainage ;  sutures. 
Recovery  was  rapidly  obtained. 

March  25.  Blepharoplasty  by  the  aid  of  a  cutaneous 
flap  from  the  frontal  region,  which  allowed  restoration  of 
the  outer  part  of  the  upper  eyelid.  Dissection  of  the  injured 
tissues  of  the  lower  eyelid  and  their  suture  in  good  position. 

Placing  of  Snellen's  sutures  to  restore  the  inferior  con- 
junctival cul-de-sac. 

After  dilatation  and  taking  a  cast  of  the  conjunctival 
cavity,  an  artificial  eye  could  be  fitted ;  discharge,  Aug.  12, 
1916. 

The  wound  of  the  frontal  sinus  had  cicatrised  without  its 
being  necessary  to  proceed  to  an  operation  for  restoration. 


DESTRUCTION  OF  THE  EYEBALL  <)r,3 

Fracture  of  the  internal  wall  of  the  left  orbit ;  destruction  of 
the  nasal  wail  and  of  the  antrum  ;  rupture  of  eyeball ; 
burying  of  th©  eye  in  the  antrum.    (Case  56.) 

A.  G.,  Infantry,  wounded  Aug.  24,  1915,  by  shell  frag- 
ments. From  Ch.  he  went  to  Arcachon,  Sep.  5,  thence 
to  Bordeaux,  Sep.  8. 

Examination. — A  large  piece  of  shell  penetrated  at  the 
level  of  the  supero-internal  angle  of  the  left  orbit,  and  came 
to  rest  at  the  anterior  surface  of  the  median  portion  of  the 
left  maxilla. 

In  its  course  it  produced  the  following  injuries — 

(1)  Laceration  of  the  inner  canthus. 

(2)  Fracture  of  the  inferior  orbital  margin  and  of  the 
floor  of  the  orbit,  entailing  the  almost  complete  destruction 
of  the  lower  eyelid. 

(3)  Rupture  of  the  left  eyeball,  reduced  to  the  condition 
of  a  shapeless  stump  at  the  bottom  of  the  conjunctival  sac. 

(4)  Fracture  of  the  maxilla,  of  the  os  unguis  and  the 
nasal  bone  on  the  left  side,  producing  an  irregular  cavity 
formed  by  the  widely  open  maxillary  sinus  and  nasal  fossse. 
These  two  cavities  communicate  by  a  wide  aperture. 

The  wound  has  been  suppurating  for  a  long  time,  and  it 
has  been  necessary  to  wait  two  months  before  being  able  to 
attempt  an  operation  for  restoration. 

Dec.  5,  1915,  an  attempt  was  made  to  close  this  opening, 
after  dissecting  up  the  cutaneous  layers  on  the  margins  of 
the  opening  into  the  antrum  and  nose.  Blepharorrhaphy 
and  superficial  sutures.  Subsequently  the  sutures  gave 
way  and  the  cicatrisation  of  the  flaps  took  place  in  bad 
position. 

Three  weeks  later,  blepharoplasty  by  transplantation  of 
a  flap  with  pedicle  taken  from  the  left  fronto -parietal  region. 
The  two  external  thirds  of  the  graft  took  by  first  intention, 
but  the  internal  third,  not  sustained  by  a  vascular  base, 
necrosed  after  a  short  time,  leaving  the  orifice  open,  but 
much  smaller  than  before. 

G.  was  sent  on  three  months'  convalescent  leave  before 
attempting  a  third  operation ;  it  was  in  the  course  of  this 
third  and  last  operation,  the  result  of  which  was  satisfactory, 
that  we  found  the  debris  of  the  eye  in  the  interior  of  the 
cavity  of  the  antrum. 

The  right  eye  was  normal.     V  =  1. 


954  FRACTURES  OF  THE  ORBIT 

Fracture  of  the  floor  of  the  right  orbit ;  cicatricial  ectropion  ; 
triaumatic  choroido-retinitis ;  large  piece  of  shell  in  the 
antrum.    (Case  57.) 

A.  L.,  Infantry,  wounded  Jan.  9,  1916,  at  M. ;  from  Ch. 
he  arrived  Feb.  4,  1916. 

Condition. — The  shell  fragment  has  penetrated  a  centi- 
metre below  the  right  inferior  orbital  margin,  in  its  median 
part;  at  its  entry  we  note  upon  the  anterior  surface  of 
the  antrum  a  depressed,  suppurating,  cicatrix;  a  probe 
introduced  into  the  orifice  leads  to  the  maxillary  sinus 
itself,  in  a  direction  from  before  backwards  and  from  below 
upwards,  to  beneath  the  floor  of  the  orbit. 

Radiography  shows  this  fracture  of  the  anterior  wall  of 
the  sinus,  and,  in  addition,  a  fracture  of  the  orbital  floor. 
The  fragment  is  found  in  the  cavity  of  the  antrum  at  its 
posterior  part,  near  the  orbit. 

The  right  eye  is  the  seat  of  extensive  disorder ;  patches 
of  peripapillary  and  macular  choroido-retinitis  (concus- 
sion lesions),  numerous  choroidal  haemorrhages  below,  on 
the  side  of  the  orbital  fracture  (contact  lesions). 

Acuity  barely  1/100. 

The  lower  eyelid  has  healed  in  a  bad  position ;  cicatricial 
ectropion  produced  by  the  retraction  of  the  palpebral  tissue 
injured  at  the  site  of  the  wound. 

At  the  first  operation,  Feb.  19,  1916,  the  wall  of  the 
antrum  was  widely  laid  open  and  a  flood  of  pus  escaped. 
The  foreign  body  was  easily  extracted  by  means  of  a 
gouge,  as  well  as  some  bone  splinters  coming  from  the 
floor  of  the  orbit.  Drainage  and  suture.  The  wound  has 
been  a  long  time  healing  by  reason  of  the  sinusitis. 

When  healed,  blepharoplasty  by  transplantation  of  a 
pedunculated  flap,  for  restoration  of  the  lower  eyelid. 

Rapid  healing  by  first  intention. 

Discharge  July  3,  1916. 

The  reading  of  these  five  case -reports  gives  a  clear 
idea  of  the  diversity  of  the  injuries  to  the  maxillary 
antrum.  In  Case  53  all  the  infero -external  orbital 
region  was  destroyed,  the  vault  and  the  anterior  wall 
of  the  maxillary  sinus  were  crushed  in ;  the  anterior 
wall  of  the  sinus  has  been  eliminated  as  a  splinter.    In 


DESTRUCTION  OF   THE  EYEBALL 


955 


Cases  54  and  55  the  anterior  wall  of  the  sinus  has 
also  been  destroyed  by  a  fragment  of  grenade,  and  its 
fragments  have  fallen  in  splinters  into  the  sinus  itself. 
Case-report  55  treats  of  a  fracture  of  the  maxillary 
sinus  by  a  large  piece  of  shell  which  was  extracted 
from  the  cavity.     The  fourth  case  (56)  is  still  more 


Fig.  57. 


interesting  in  the  sense  that,  besides  the  large  opening 
allowing  the  maxillary  sinus  to  communicate  with  the 
nasal  fossae,  we  found,  at  the  time  of  one  of  the  repara- 
tory  operations  which  have  been  done,  the  left  eye 
crushed  down  into  the  sinus.  Finally,  in  the  fifth 
report  (Case  57),  given  here  as  a  specimen,  we  again 
found  a  piece  of  shell  (Fig.  57)  in  the  posterior  part  of 
the  cavity  of  the  sinus,  against  the  floor  of  the  orbit. 


956  FRACTURES  OF  THE  ORBIT 


(h)  Frontal  Sinus 

The  frontal  sinus  is  sometimes  attacked  alone  by  the 
instruments  of  violence  which  fracture  the  orbital  walls  ; 
here,  most  frequently,  we  have  to  do  with  a  bullet  whose 
course  from  below  upwards,  or  from  above  downwards, 
meets  the  frontal  sinus  and  traverses  it.  Out  of  the 
three  cases  we  give  of  lesions  of  the  frontal  sinus,  two 
are  concerned  with  bullet  wounds,  the  third  with 
traumatism  by  shell  fragment. 


Fracture  of  the  supero-internal  orbital  wall ;    opening  of  the 
left  frontal  sinus.    (Case  58.) 

L.  H.,  Infantry,  wounded  Sep.  25,  1915,  at  Saint-H., 
by  a  rifle  bullet  at  the  level  of  the  inner  extremity  of  the  left 
eyebrow.  Transported  to  Saint-H.,  he  reached  our  service 
Oct.  5,  complaining  of  diplopia. 

Condition. — The  projectile  has  entered  at  the  supero- 
internal  angle  of  the  leit  orbit  and  emerged  at  the  internal 
third  of  the  right  eyebrow,  at  a  centimetre  distance  from 
the  latter. 

In  its  course  it  has  fractured  the  left  frontal  sinus,  which 
at  the  time  of  our  examination  is  widely  open. 

Palpation,  very  painful,  reveals  the  existence  of  a  notch 
of  the  orbital  margin,  at  the  point  of  penetration  of  the 
bullet.  In  addition  there  is  a  depressed  cicatrix  adherent 
to  the  deep  parts. 

Radiography  confirms  the  fracture  of  the  left  frontal 
sinus.  The  left  eyeball  is  normal ;  no  lesion  of  the  refringent 
media  or  deep  membranes  to  be  found. 

Visual  acuity  of  the  left  eye  equals  10/10. 

H.  complains  of  a  very  distressing  diplopia  following  the 
traumatism.  Study  of  the  false  image  reveals  paralysis  of 
the  left  superior  oblique  muscle.  It  is  probable  that  the 
projectile  has  divided  the  pulley  of  the  muscle  situated  at 
the  fractured  spot. 

The  frontal  wound  had  cicatrised  spontaneously,  and 
H.  went  on  convalescent  leave  with  persistent  diplopia 
and  almost  constant  violent  headaches. 


DESTRUCTION   OF   THE  EYEBALL       *   957 

Fracture  of  the  facial  bones  by  a  bullet ;   fracture  of  the  frontal 
sinus  and  of  the  ethmoid  ;    adipose  graft.    (Case  59.) 

E.  H.,  Infantry,  was  wounded  Oct.  17,  1915,  at  A.  Sent 
to  Sainte-Menehoiild,  afterwards  to  Vichy,  where  ablation 
of  splinters  and  extraction  of  the  ethmoid  were  effected. 

Condition. — On  arrival  July  7,  1915,  it  was  found  that 
the  bullet  had  penetrated  the  root  of  the  nose,  passed 
along  the  internal  wall  of  the  right  orbit,  without  fractur- 
ing it,  traversed  the  superior  maxilla  and  the  roof  of  the 


Fig.  58. 

mouth,  comihg  to  rest  in  the  lateral  part  of  the  neck.  In 
its  course  it  had  broken  into  the  frontal  sinus  and  the 
ethmoid. 

The  eyes  are  intact,  and  their  visual  acuity  is  normal. 

The  sole  lesion  evident  is  obstruction  of  the  right  lacrymal 
passages,  probably  due  to  a  fracture  of  the  nasal  canal. 

The  bullet  was  extracted  Aug.  9,  1915,  by  the  aid  of  the 
classic  incision  used  for  ligature  of  the  carotid;  it  was 
found  near  the  superior  border  of  the  thyroid  cartilage, 
under  the  anterior  border  of  the  sterno-cleido-mastoid. 

Post-operative  progress  normal. 

H.  left  hospital  in  Sep.  1915,  with  persistence  of  lacryma- 
tion  on  the  right  side. 

On  his  return  from  convalescent  leave  we  proceeded  to 


958   •  FRACTURES  OF   THE  ORBIT 

resect  the  vicious  cicatrix  at  the  root  of  the  nose.  After 
splitting  the  cutaneous  covering  the  cavity  was  filled  in 
by  the  aid  of  fatty  tissue  taken  from  the  right  buttock. 

Union  by  first  intention. 

The  adipose  graft  gave  an  excellent  result  from  the 
aesthetic  point  of  view. 

Fracture  of  the  left  fronto-orbital  region  involving  the  frontal 
sinus  ;  haemorrhage  into  the  vitreous  body  ;  adipose  graft. 

(Case  60.) 

E.  B.,  Infantry,  wounded  Sep.  25,  1915,  at  B.,  by  a  shell ; 
via  Perigueux  to  Bordeaux,  where  he  arrived  Nov.  9, 
1915. 

Condition-  The  piece  of  shell  had  produced  a  wound 
seven  centimetres  long,  beginning  at  the  left  upper  eyelid, 
implicating  the  end  of  the  eyelid  and  the  frontal  sinus, 
which  was  laid  widely  open.  The  wound  had  become 
infected,  and  suppuration  has  been  fairly  abundant. 

On  the  patient's  arrival  the  wound  of  the  sinus  had  a 
fistulous  aspect,  some  drops  of  purulent  fluid  welling  up. 

The  upper  eyelid  is  divided  at  the  site  of  the  internal 
third.  The  eyeball,  severely  contused,  is  of  normal  ten- 
sion, but  in  the  vitreous  body  numerous  clots  float  (trau- 
matic haemorrhage) ;  visual  acuity  equals  4/10. 

Radiography  shows  a  large  loss  of  bony  substance  in  the 
region  of  the  frontal  bone,  its  base  in  the  form  of  a  crescent 
with  the  concavity  posterior. 

During  his  stay  in  hospital  there  was  elimination  of 
several  bone  splinters  from  the  fistulous  opening  into  the 
sinus;  slow  healing. 

When  suppuration  had  ceased  we  proceeded  to  effect 
palpebral  restoration  by  suture  of  the  two  divided  portions. 
Result  excellent.  The  sinus  is  fiUing  up  little  by  little, 
giving  rise  to  a  depressed  cicatrix.  May  25,  1916,  adipose 
graft.  The  skin,  very  adherent  to  the  deep  parts,  required 
most  delicate  dissection. 

The  graft,  taken  from  the  left  buttock,  preserved  perfect 
vitality,  and  healing  took  place  by  first  intention. 

B.  left  in  June  1916.  The  acuity  of  the  left  eye  was 
always  4/10. 

Case  58  is  a  type  of  fracture  localised  as  it  were  by 


DESTRUCTION  OF  THE  EYEBALL  959 

the  sinus  itself ;  the  sole  region  of  the  orbit  concerned 
is  that  which  limits  the  sinus  at  its  internal  and  inferior 
aspect,  and  the  only  visual  disorder  ascertained  was 
impotence  of  the  superior  oblique,  due  to  the  destruc- 
tion of  the  pulley  of  this  muscle.  Case  59  is  in  much 
the  same  condition ;  the  bullet,  as  shown  in  Fig.  58, 
has  penetrated  at  the  root  of  the  nose  and  passed  along 
the  internal  wall  of  the  orbit  without  fracture,  traversed 
the  maxilla  and  the  floor  of  the  mouth,  coming  to  rest 
in  the  carotid  region  whence  it  was  extracted.  In  this 
case,  in  short,  we  were  dealing  with  a  fracture  involving 
the  orbit  to  the  minimum,  and  traversing  the  face  from 
top  to  bottom  while  causing  as  little  mischief  as  possible. 
Shell  fragments  affect  the  parts  injured  more  severely ; 
in  Case  60  we  have  to  d^  with  a  shell  fragment  which 
has  caused  a  wound  seven  centimetres  long  in  the  region 
of  the  frontal  sinus,  which  was  widely  laid  open ;  the 
whole  anterior  wall  of  the  sinus  was  eliminated,  and 
a  deep  cupuliform  cicatrix  produced,  which  was  satis- 
factorily filled  up  by  an  adipose  graft. 


(c)  Cranial  Cavities 

The  cases  in  which  the  cranial  cavity  has  been 
opened  ought  evidently  to  be  considered  as  cases  of 
the  gravest,  quoad  vitam,  with  which  the  ophthalmolo- 
gist can  have  to  deal.  At  the  same  time  it  would  be 
an  error  to  believe,  even  when  the  cerebral  substance 
is  largely  laid  bare  and  a  portion  of  this  substance 
has  been  sacrificed,  that  the  prognosis  is  necessarily 
fatal.  We  shall  cite  cases  subsequently,  which  demon- 
strate the  relative  benignity  of  such  disorders.  In  the 
literature  (brought  under  contribution  as  little  as 
possible  in  this  book),  we  find  similar  cases  discussed. 
We  shaU  content  ourselves  with  making  particular 
mention  of  those  cases  which  have  been  recorded  by 
our  colleagues,  the  heads  of  the  ophthalmic  centres, 
in  their  monthly  reports;  the  cases  observed  at  the 
clinic  of  the  Quinze-Vingts  by  Valude,  Chevallereau, 


960  FRACTURES  OF   THE  ORBIT 

Chaillons  and  Pompeani  merit  particular  attention 
(Report  of  January,  1915). 

In  one  case,  a  rifle  bullet,  penetrating  the  inter- 
superciliary  region,  traversed  the  anterior  lobes  of  the 
brain,  the  left  frontal  sinus,  the  orbit  and  maxillary 
sinus,  etc..  The  patient  lost  two  tablespoonfuls  of 
cerebral  matter,  but  remained  in  excellent  general 
condition.  Another  patient,  wounded  by  a  piece  of 
shell  in  the  median  and  superior  portion  of  the  frontal 
bone,  presented  a  large  opening  communicating  with 
the  orbital  cavity  and  quite  near  the  frontal  lobes,  with 
pulsations  synchronous  with  the  cardiac  beat ;  these 
two  patients  recovered.  A  third  case,  wounded  in  the 
same  manner,  died.  We  have  cases  to  set  beside 
these  to  the  number  of  four,  and,  in  one  only,  was  the 
termination  unfortunate.  We  report  them  here,  as 
briefly  as  possible,  but  in  all  their  essential  details,  on 
account  of  the  gravity  of  the  disorders  concerned. 

We  are  of  opinion  that  we  should  distinguish  in  the 
cranial  trouble  consecutive  to  orbital  fractures,  or 
rather  concomitant  with  them,  two  orders  or  classes  of 
cases  :  those  in  which  the  phenomena  observed  are 
sUght,  temporary,  without  important  symptoms ;  and 
those  in  which  the  aspect  of  the  affection  has  been  dis- 
turbing from  the  outset,  by  reason  of  inflammatory 
manifestations. 

We  publish  these  cases  according  to  their  increasing 
gravity,  terminating  by  the  only  fatal  case  observed  in 
our  clinic. 


Fracture  of  the  left  orbit ;   retrobulbar  neuritis,  L.  £. 

(Case  61.) 

H.  C,  Infantry,  wounded  May  19,  1915,  at  N.  V.  by  a 
shell.  Trephined  the  same  day,  he  was  afterwards  sent  to 
Rennes,  Saintes,  and  Bordeaux,  where  he  came  under  our 
observation. 

Condition. — There  is  an  injury  of  the  left  fronto -parietal 
region  and  the  orbito-ocular  region.  At  two  centimetres 
from  the  external  angle  of  the  orbit  there  is  a  depression 


DESTRUCTION  OF  THE  EYEBALL 


961 


in  which  one  can  bury  the  tip  of  the  index  finger.  The 
external  wall  of  the  orbit  is  the'^efore  fracuured. 

The  patient  complains  since  the  injury  of  enfeeblement 
of  the  left  eye,  the  acuity  of  which  equals  no  more  than 
1/10,  verified  by  the  tests  in  use  to  check  malingering. 

Ophthalmoscopic  examination  reveals  no  lesion.  The 
disc  and  the  vessels  are  normal.  The  visual  field  is  slightly 
contracted,  but  there  is  no  scotoma.     We  are  probably 


Fig.  59. 


dealing  with  a  retrobulbar  neuritis,  consecutive  to  the 
traumatism. 

In  addition  there  is  paralysis  of  the  external  rectus 
muscle  of  the  eye,  causing  homonymous  diplopia,  which 
the  patient  corrects  by  inclining  his  head  towards  the  left 
shoulder. 

C,  besides  his  orbito-ocular  troubles,  has  a  fracture  of 
the  mandible. 

He  also  presents  some  derangement  of  the  nervous 
system.  When  upright,  he  is  seized  with  vertigo,  and  is 
obliged  to  lean  on  a  stick  to  support  himself  with  his  hands. 
Lying  down,  the  vertigo  is  equally  frequent,  but  much  less 
violent. 

Complete  deafness  on  the  left  side. 

Cutaneous  anaethesia  of  the  left  part  of  the  face  is  noted. 
Disappearance  of  the  achillean  and  plantar  reflexes.     C. 


962 


FRACTURES  OF  THE  ORBIT 


complains  of  headaches  and  violent  buzzing  noises.  His 
condition  is  the  same  at  the  time  these  notes  are  written, 
but  the  visual  acuity  equals  1/3. 

Fracture  of  the  left  orbital  vault  by  shell  fragment ;  perforation 
of  the  globe  ;  total  detachment  of  the  retina.    (Case  62.) 

J.  N.,  Infantry,  wounded  Sep.  25,  1016,  at  S.  by  a  shell; 
from  Chalons  Oct.  4,  at  Bordeaux  Oct.  7. 

He  presents  an  injury  of  the  left  fronto-parietal  region, 
at  the  level  of  the  descending  branch  of  the  frontal.     The 


Fig.  60. 

fragment  has  penetrated  here  into  the  cranial  cavity,  after 
having  fractured  the  frontal  portion  of  the  orbital  vault. 

By  the  orifice  of  entry  we  note  an  extensive  loss  of  bone 
substance  of  the  size  of  a  crown-piece,  produced  by  the 
fracture  and  by  the  trephining  done  at  S.,  Sep.  26,  1915, 
and  a  second  time  at  Bordeaux,  Oct.  21,  1915  (extraction  of 
fragments  and  splinters  and  reduction  of  a  cerebral  hernia). 

The  eyeball  has  been  perforated  at  its  posterior  part  and 
is  now  reduced  to  the  condition  of  a  stump,  not  painful 
spontaneously  or  on  pressure  (traumatic  irido-choroiditis 
and  total  detachment  of  the  retina).  The  right  eye  is 
intact. 

R.  E.         V  =  10/10. 
L.  E.         V  =  0. 


DESTRUCTION  OF  THE  EYEBALL  963 

Radiography  shows  the  presence  in  the  neighbourhood 
of  the  wound  of  two  projectiles  (shell  fragments)  which  have 
not  been  extracted. 

A  fortnight  before  the  second  trephining,  N.  was  seized 
with  complete  aphasia,  which  disappeared  after  surgical 
interference  and  has  not  recurred  since. 

No  disorder  of  the  nervous  system,  central  or  peri- 
pheral. 

His  general  condition  has  been  most  satisfactory,  but  on 
March  12,  1916,  without  cause,  the  patient  had  a  sudden 
loss  of  consciousness,  which  lasted  about  half  an  hour. 

Fracture  of  the  apex  of  the  left  orbit ;  bilateral  papillary  stasis  ; 
"  mal  comitlal "  (epilepsy).    (Case  63.) 

F.  B.,  Chasseur  a  pied,  wounded  Jan.  19,  1915,  at  A., 
by  shell.  The  fragment  has  penetrated  at  the  level  of  the 
left  temporo-maxillary  articulation.  The  patient  remained 
eight  days  unconscious  and  delirious.  B.  was  operated 
upon  at  Blois,  July  3.  His  case-sheet  bears  the  following- 
note  :  "  Extraction  of  a  large  piece  of  shell,  lodged  behind 
the  left  zygomatic  process  and  the  inferior  maxilla.  When 
the  fragment  was  removed  cerebral  matter  was  seen  in  the 
wound.  By  radioscopy,  a  probe  introduced  into  the 
breach  passes  into  the  cranium  at  the  level  of  the  temporal 
convolutions,  passing  behind  the  eyeball  and  through  the 
fractured  wing  of  the  sphenoid.     No  operation." 

Since  his  admission,  July  18,  1915,  B.  has  had  two  or 
three  relapses,  crises  of  delirium,  preceded  by  headaches 
and  a  sensory  aura  (sensation  of  a  bad  smell).  The  crises 
are  not  accompanied  by  loss  of  consciousness,  but  by  abso- 
lute amnesia,  pallor  of  the  face  and  difficulties  of  speech. 

The  patient  was  examined  with  reference  to  these  attacks 
in  the  neurological  clinic,  where  this  diagnosis  was  made : 
"  epileptiform  attacks,  probably  of  commissural  origin 
consecutive  to  traumatism."  No  disturbance  of  the  peri- 
pheral nervous  system.  The  orifice  of  entry  of  the  pro- 
jectile is  found  a  little  in  front  of  the  left  temporo-maxillary 
articulation.  Radiography  does  not  allow  us  definitely  to 
assert  the  presence  of  a  visible  fracture,  and  there  is  no 
trace  of  a  foreign  body. 

There  is  no  trouble  with  the  extrinsic  musculature  of 
the  two  eyes.     On  the  left  one  notices  a  breach  in  the 


964 


FRACTURES  OF   THE  ORBIT 


iris  similar  to  that  produced  by  an  iridectomy,   but  B. 
affirms  that  he  has  never  been  operated  upon. 

The  transparent  media  are  normal .  The  papillae  present 
the  classic  type  of  choked  disc,  and  this  oedema  is  more  marked 
on  the  left  than  on  the  right. 


R.  E. 
L.  E. 


with 
with 


2-50  D  sph., 
1  D  sph., 


V 
V 


1/10. 
2/10. 


In  consideration  of  the  meningeal  irritation  and  the  ante- 
cedents surgical  interference  was  withheld,  and  B.  went  on 
convalescent  leave  Jan.  10,  1916. 


Fig.  61. 


Fracture  of  the  left  orbital  region  in  the  fronto-temporal  part ; 
fracture  of  the  orbital  vault ;  loss  of  cerebral  substance  ; 
contusion  of  the  globe  ;    haemorrhage  into  the  vitreous. 

(Case  64.) 

B.  v.,  Infantry,  wounded  June  27,  1916,  at  M.  by  shell, 
in  the  left  fronto-temporal  region.  The  field  hospital  case- 
sheet  bears  the  following  notes  :  "A  large  shell  fragment 
has  penetrated  the  left  fronto-temporal  region  at  two  centi- 
metres above  the  supero-external  angle  of  the  left  orbit, 
severely  fracturing  the  orbital  vault,  opening  direct  com- 
munication with  the  encephalon  (Fig.  55,  p.  949).  Next,  it 
has  divided  the  left  optic  nerve,  seriously  contused  the  eye- 


DESTRUCTION  OF  THE  EYEBALL  9(15 

ball,  and,  after  having  traversed  the  nasal  fossse,  has  lodged 
on  the  anterior  surface  of  the  right  maxillary  sinus,  whence 
it  was  extracted  June  28,  1916.  At  the  moment  of  the 
injury  there  was  an  abundant  escape  of  cerebral  matter. 

In  the  following  days  the  temperature  rose ;  enormous 
exophthalmos  appeared,  due  probably  to  inflammatory 
reaction  of  the  intra-orbital  tissues.  The  globe  was  enu- 
cleated July  2,  1916,  and  the  vitreous  was  found  to  be 
full  of  blood-clot.  Then  was  remarked  a  very  extensive 
loss  of  bone  substance  from  the  vault  and  the  supero- 
external  wall  of  the  orbit,  making  a  communication  be- 
tween it  and  the  cranial  cavity  on  the  one  side,  and  the 
exterior  on  the  other. 

Rapid  improvement  in  the  condition  of  the  patient, 
whom  we  saw  Oct.  14.  At  this  date  there  was  complete 
cicatrisation  of  the  left  fronto-temporal  fracture,  where 
there  was  the  sensation  of  cerebral  pulsation. 

An  artificial  eye  was  fitted. 

There  is  no  derangement  of  the  central  or  peripheral 
nervous  system. 

K.  E.  normal;  with  +  1  D  cyl.,  axis  165°,  V  =  10/10. 


Fracture  of  the  right  orbit  by  grenade  ;  rupture  of  the  left  eye- 
ball ;  cerebral  abscess,  recovery.    (Case  65.) 

J.  B.,  Infantry,  wounded  Jan.  11,  1916.  Admitted 
Feb.  25,  in  a  state  of  marked  prostration;  torpor,  low 
temperature ;  slight  Kernig's  sign,  no  stiffness  of  the 
neck,  pulse  very  slow  (46).  Two  pieces  of  grenade  had 
penetrated  the  lower  portion  of  the  right  orbit,  traversed 
the  eyeball,  which  is  reduced  to  its  scleral  envelope,  per- 
forated the  orbital  vault,  and  come  to  rest  in  the  cerebral 
substance  in  the  right  superior  parietal  region. 

Radiography  enables  us  to  locate  the  two  projectiles, 
and  at  the  same  time  to  ascertain  the  loss  of  bone  sub- 
stance of  the  orbit.  The  general  symptoms,  added  to 
these  clinical  reports,  suggest  a  sub-dural  cerebral  abscess 
in  course  of  development. 

Feb.  20,  1916,  enucleation  of  the  stump  was  performed; 
then,  by  an  incision  at  the  level  of  the  right  eyebrow,  the 
orbital  periosteum  was  detached  by  means  of  a  gouge. 
The  whole  roof  of  the  orbit  was  thus  laid  bare,  and  we 


96G 


FRACTURES  OF    THE  ORBIT 


Fig.  G2. 


noted  the  presence  of  two  bone  apertures  in  the  upper 
part,  one  of  which  was  the  size  of  a  half-franc  piece. 

A  splinter,  1  cm.  long 
by  4  mm.  wide,  was  ex- 
tracted, and  the  orifice 
cleaned  by  means  of  a 
blunt  curette.  A  large 
quantity  of  purulent 
liquid  welled  up  from 
the  sub-dural  region. 
The  parts  were  washed 
with  hydrogen  peroxide 
lotion;  by  removal  of 
the  external  orbital  pro- 
cess, dependent  drainage 
was  arranged.     Sutures. 

Post-operative  condi- 
tions uneventful.  The 
temperature,  after  hav- 
ing risen  to  38"6°  C. 
(101-5°  Fahr.),  quickly 
returned  to  the  normal, 
and  the  pulse  to  72. 

May  7,  1916,  B.  had 
completely  recovered, 
and  his  general  condir 
tion  was  most  satisfac- 
tory. The  headaches 
had  disappeared,  and 
Fig.  63.  the  patient  attended  to 

the  occupations  of  daily 
life  without  complaining  of  his  injury. 

May  23,  a  palpebral  fibrous  band  was  incised ;  the  wearing 
of  an  artificial  eye  then  became  practicable. 


Smash  of  the  orbital  vault ;    rupture  of  eyeball ;    intra-orbital 
menlngo-encephalocele.    (Case  66.) 

C.  R.,  Infantrj^  wounded  in  A.,  Feb.  1,  1915,  by  rifle 
bullet.  Immediate  loss  of  consciousness.  Treated  in  field 
ambulance.  He  there  underwent  an  operation,  upon  the 
nature  of  which  we  have  been  unable  to  obtain  information 

Admitted  April  29,  1915. 


DESTRUCTION  OF   THE  EYEBALL  9G7 

Condition. — The  projectile  had  penetrated  in  the  right 
frontal  region,  at  about  3  cm.  from  the  supero-external 
angle  of  the  right  orbit.  After  having  traversed  the 
orbital  cavity  from  side  to  side  it  emerged  at  the  root  of 
the  nose. 

Palpation  of  the  injured  region  does  not  enable  any 
bony  depression  to  be  detected,  except  at  the  point  of 
penetration  of  the  bullet.     No  cerebral  pulsation. 

The  eyelids  are  intimately  adherent  to  each  other  over 
their  whole  extent  (total  symblepharon) .  On  palpation 
through  this  palpebral  veil  there  is  the  sensation  of  a 
resistant  mass,  not  fluctuating;  and — we  insist  on  this 
detail — no  pulsation  synchronous  with  the  cardiac  con- 
tractions was  perceived;  we  thought  it  was  probably  the 
right  eyeball,  hidden  behind  the  eyelids. 

Radiography,  moreover,  gave  negative  results,  and 
revealed  no  bony  damage. 

May  10,  1915,  intending  to  proceed  with  enucleation  of 
the  right  eyeball,  the  eyelids  were  carefully  incised  at  the 
line  of  mutual  adhesion.  Immediately  a  greenish  liquid, 
holding  in  suspension  some  purulent  clots,  flowed  out  in 
abundance. 

After  having  enlarged  the  incision  it  was  seen  that  we 
were  dealing  with  an  intra-orbital  meningeal  cyst,  pro- 
ducing under  tension  a  hernia  behind  the  palpebral 
curtain. 

The  cerebro-spinal  liquid  having  escaped,  we  could  see, 
at  the  bottom  of  the  orbital  cavity,  the  cerebral  substance 
to  which  a  large  opening  in  the  orbital  vault  gave  free 
passage.  No  trace  of  the  eyeball.  Immediate  suture  of 
the  operation  wound,  after  drainage. 

The  same  evening  the  pulse  slowed  down,  the  patient 
became  delirious,  and  the  temperature  rose  to  39"8°  C. 
(103"6°  Fahr.).  Symptoms  of  meningo-encephalitis  ap- 
peared, and  R.  died  May  12,  1915,  from  suppurative 
meningitis ;  the  cerebro-spinal  fluid  withdrawn  after  punc- 
ture contained  pus  in  great  quantity. 

The  first  patient,  as  a  result  of  serious  injury  to  the 
temple  which  necessitated  trephining,  presented  only 
certain  troubles  in  the  nervous  system,  vertigo,  deafness 
of  the  left  side,  cutaneous  anaesthesia  of  the  left  side 


968  FRACTURES  OF   TEE  ORBIT 

of  the  face,  disappearance  of  the  plantar  and  tendo 
Achillis  reflexes,  and  diminution  of  visual  acuity  of 
the  left  eye.  The  subject  of  Case  62  presented  a  large 
loss  of  substance  in  the  left  parietal  region,  with,  as 
the  only  cerebral  disorder,  an  aphasia  which  disappeared 
completely  after  trephining.  The  patient  in  Case  63 
was  wounded  by  a  large  piece  of  shell  which  lodged 
behind  the  left  zygomatic  process  and  the  mandible ; 
at  the  time  of  extraction  of  the  projectile  cerebral 
matter  appeared ;  a  probe  introduced  into  the  opening 
passed  through  the  fractured  wing  of  the  sphenoid  into 
the  temporal  convolutions,  far  from  the  eyeball.  From 
the  time  of  his  admission  under  our  care  the  patient  had 
crises  of  delirium,  preceded  by  pains  in  the  head  and  a 
sensory  aura  (sensation  of  an  unpleasant  smell) ;  the 
crises  were  not  accompanied  by  loss  of  consciousness, 
but  by  amnesia,  pallor  of  the  face,  and  difficulties  of 
speech  He  had  also  serious  disturbances  of  vision ; 
there  was  acute  optic  neuritis  on  each  side,  and  we 
have  grave  fears  for  this  patient's  future,  at  least  so 
far  as  his  eyes  are  concerned. 

Case  65  is  still  more  interesting ;  the  patient  was 
struck  by  portions  of  grenade,  which,  after  having 
destroyed  the  eye  and  smashed  up  the  roof  of  the 
orbit,  came  to  rest  in  the  brain  (Figs.  62  and  63). 
They  produced  phenomena  of  meningo -encephalitis, 
with  an  abscess  under  the  frontal  lobe.  We  per- 
formed an  operation  consisting  in  the  detachment  of 
the  whole  of  the  periosteum  of  the  orbital  vault ;  a 
large  fragment  was  removed,  and,  as  in  an  atypical 
trephining,  the  edges  of  the  opening  resulting  from 
the  loss  of  substance  were  rounded  off  in  such  a 
way  as  greatly  to  enlarge  it ;  a  large  quantity  of  pus 
flowed  away.  The  cerebral  phenomena  related  in  the 
notes  slowly  disappeared,  and  the  patient  recovered, 
apparently  retaining  without  damage,  at  least  for  the 
present,  the  two  intra -cerebral  foreign  bodies  which 
are  seen  in  Figs.  62  and  63,  and  which  the  radiogram 
reveals  clearly. 

We  also  draw  attention  to  another  case  of  fracture 


DESTRUCTION  OF  THE  EYEBALL  969 

of  the  left  orbital  vault  with  loss  of  cerebral  substance, 
in  which  recovery  was  readily  obtained  without  inflam- 
matory mishaps  and  without  cerebral  disorders  of  any 
kind. 

It  was  not  so,  unhappily,  with  the  last  case,  which 
terminated  by  death.  An  unsuspected  fracture  of  the 
orbital  vault  was  present  in  a  patient  coming  under  our 
care  from  a  distant  centre ;  he  had  a  fracture  of  the 
superior  orbital  margin ;  radiography  showed  neither 
lesion  of  the  roof  of  the  orbit  nor  foreign  body,  and 
we  felt  in  the  orbit  a  soft  swelling,  so  deep  that  it 
appeared  to  us  to  be  a  shrunken  eye.  In  attempting 
to  remove  it  we  opened  a  cyst,  filled  with  a  suspicious 
serous  fluid,  communicating  with  the  cranial  cavity, 
and  the  patient  rapidly  succumbed  to  meningo-ence- 
phalitis.  It  is  the  only  unfortunate  case  of  this  kind 
we  have  met  with. 


CHAPTER    VI 

TREATMENT  OF  FRACTURES  OF  THE  ORBIT 
AND  THEIR  COMPLICATIONS 

The  immediate  treatment  which  the  military  surgeon 
at  the  front  should  apply  to  fractures  of  the  orbit 
will  not  detain  us  long ;  the  first  reason  is  that 
we  have  been  working  far  removed  at  the  base,  for 
the  past  thirty  months,  and  we  have  only  seen  frac- 
tures of  which  the  most  recent  were  several  weeks 
old;  the  second  reason  is  that  in  reality  it  is  the 
complications  of  these  fractures  which  present  special 
indications. 

The  fractures  themselves  require,  as  a  rule,  only 
the  ordinary  attentions  of  antisepsis  and  asepsis, 
flushing  with  hydrogen  peroxide,  the  application  of 
tincture  of  iodine  followed  by  an  appropriate  dressing, 
without  prejudice  to  the  immediate  injection  of  anti- 
tetanic  serum. 

The  most  important  question  which  arises  is  to 
know  when  it  is  permissible,  in  order  to  ascertiain  the 
extent  of  the  mischief,  to  probe  the  track  of  the 
projectile ;  the  best  principle  is  to  abstain  until  such 
time  as  carefully  executed  radiography  has  permitted 
the  offending  foreign  body  to  be  localised,  and  thus 
enabled  the  surgeon  to  appreciate  exactly  the  dangers 
inherent  to  searching  for  it  and  the  advantages  which 
may  follow  its  extraction. 

It  will  be  well  to  point  out  here  the  immediate 
steps  to  be  taken  in  the  different  fractures  of  the  orbit, 
according  to  the  region  injured. 

970 


Plate  I 

Ophthalmoscopic  appearances,  direct  method. 


Fig.  L— R.  E.  Fracture  of  left 
frontal  region,  severe  con- 
cussion, haemorrhage  into  the 
sheaths  of  the  right  optic 
nerve,  right  macular  haemor- 
rhage. 


Fig.  2. — L.  E.  Fracture  of  left 
orbital  arch  and  outer  margin, 
concussion  of  tissues  of 
orbit,  macular  haemorrhage, 
optic  atrophy. 


Fig.  3. — R.  E.  Fracture  of  floor 
of  orbit  and  of  right  inferior 
orbital  margin ;  macular 
choroido-retinitis  (concussion 
lesion);  atrophic  and  pig- 
mented choroido-retinitis 
(contact  lesions). 


Fig.  4. — R.  E.  Fracture  of  the 
external  orbital  margin ; 
macular  and  peri- papillary 
choroido-retinitis  (concussion 
lesions). 


Plate  II 

Ophthalmoscopic  appearances,  direct  method. 


Fig.  1. — L.  E.  Fracture  of  as- 
cending process  of  malar  bone 
and  of  infero-external  orbital 
margin ;  macular  haemorrhage 
and  choroido-retinitis  (con- 
cussion lesions). 


Fig.  2.— R.  E.  Fracture  of 
frontal  sinus  with  depression. 
Macular  choroiditis  (concus- 
sion lesions);  choroido-retin- 
itis above  and  to  the  inner 
side  (contact  lesions). 


Fig.  3.— R.  E.  Fracture  of  the 
malar  bone  and  of  the  inferior 
orbital  margin ;  macular 
choroido-retinitis,  rupture 
(concussion lesion);  choroido- 
retinitis  and  detachment  of 
the  retina  (contact  lesions). 


Fig.  4.— R.  E.  Fracture  of  the 
floor  of  the  orbit ;  peri-papil- 
lary choroiditis  (concussion 
lesion) ;  haemorrhage  and 
pigmented  choroido-retinitis 
below  (contact  lesions). 


Plate  III 

Ophthalmoscopic  appearances,  direct  method. 


Fig.  1. — R.  E.  Fracture  of  the 
external  orbital  process  and 
wall  of  the  orbit ;  avulsion  of 
optic  nerve,  ddep  excavation. 


Fig.  2. — L.  E.  Fracture  of  ex- 
ternal orbital  wall,  bullet 
having  traversed  the  orbit; 
partial  avulsion  of  optic  nerve'-; 
below,  traumatic  proliferat- 
ing choroido-retinitis. 


Fig.  3.— R.  E.  Fracture  of 
facial  bones ;  traumatic  pro- 
liferating choroido-retinitis. 


Fig.  4.— L.  E.  Fracture  of  the 
external  orbital  wall  and  in- 
ferior margin;  laceration  of 
the  retina  and  choroid  in  the 
macular  region  (concussion 
lesion);  proliferating  cho- 
roido-retinitis; atrophic  and 
pigmented  choroido-retinitis 
below  (contact  lesion). 


Plate  IV 

Ophthalmoscopic  appeararices,  direct  method. 


Fig.  1. — L.  E.  Fracture  of  the 
•  superior  orbital  margin; 
intra-orbital  foreign  body, 
section  of  optic  nerve ;  pro- 
liferating choroido-retinitis 
of  the  superior  papillo-macu- 
lar  region. 


Fig.  2.— R.  E.  The  projectile 
has  traversed  the  facial  bony- 
mass  without  touching  the 
right  eye  :  laceration  of  the 
right  macular  retina  and  cho- 
roid; proliferating  choroido- 
retinitis  (concussion  lesion). 


Fig.  3. — L.  E.  Fracture  of  the 
inferior  wall  of  the  orbit, 
with  propulsion  of  the  bony 
fragment  towards  the  eye ; 
large  laceration  of  the  retina 
and  choroid  (contact  lesion). 


Fig.  4.— R.  E.  Fracture  of  the 
external  orbital  wall ;  rupture 
of  the  choroid  in  the  macular 
region  (concussion  lesion) ; 
proliferating  choroido-retin- 
itis. 


Plate  V 
Ophthalmoscopic  appearances,  indirect  method. 


Fig.  1.— Case  31.  The  laceration 
crossing  the  choroid  can  be  de- 
tected in  the  midst  of  the  abun- 
dant pigmentation  which  covers 
the  macular  region  (concussion 
lesion). 


Fig.  2. — Case  32.  Note  the  retinal 
vessels  passing  above  the  cho- 
roidal lacerations.  One  is  inter- 
rupted in  its  course  and  is  covered 
by  a  tract  of  proliferating  retinitis 
(concussion  lesion). 


Fig.  3,— Case  33.  The  pigment 
here  prpbably  conceals  fine  cho- 
roidal lacerations  (concussion 
lesion). 


Fig.  4. — Case  34.  The  retina  is  in- 
tact at  the  site  of  the  choroidal 
lacerations,  as  demonstrated  by 
the  vessels  (concussion  lesions). 


Plate  VI 


Fig.  L— Case  16.  The  retina 
itself  has  been  torn,  Hke  the 
choroid.  Examination  of 
the  vessels  furnishes  the 
proof. 


Fig.  2. — The  disc  is  atrophied; 
a  vast  laceration  of  the  choroid 
has  destroyed  the  macular 
region;  the  bullet  has  divided 
the  optic  nerve,  traversing  the 
orbit  without  touching  the  eye 
(concussion  lesion). 


Fig.  3. — Case  37.  The  macular 
region  is  the  seat  of  a  vast 
choroidal  laceration  sur- 
rounded by  pigment  (concus- 
sion lesion). 


Fig.  4. — Case  38.  The  posterior 
myopic  staphyloma  is  doubtless 
an  old  lesion;  but  the  chor- 
oidal laceration  in  the  macular 
region  is  due  to  traumatism 
(concussion  lesion). 


TREATMENT  OF  COMPLICATIONS  971 

We  shall  not  speak  of  the  treatment  indicated  in 
indirect  fractures,  because  these  fractures  do  not  exist 
in  military  surgery.  We  do  not  contest  their  exist- 
ence in  civil  surgery ;  falls  on  the  cranium  may  pro- 
duce radiatibns  over  the  orbital  vault,  but  gunshot 
fractures  of  the  skull  do  not  lead  to  such  radiations, 
and  in  this  chapter  on  therapeutics  we  need  not  con- 
cern ourselves  with  them. 

The  immediate  care  to  be  devoted  to  direct  fractures 
will  alone  occupy  us ;  we  shall  consider  successively 
fractures  (a)  of  the  superior  margin  and  wall,  (fe)  of 
the  internal  margin  and  wall,  (c)  of  the  inferior  margin 
and  wall,  and  (d)  of  the  external  margin  and  wall. 

(a)   Superior  Orbital  Margin  and  Wall 

If  a  simple,  not  compound,  fracture  be  in  question, 
a  light  compress  suffices.  If  there  is  an  open  wound 
any  detached  fragment  should  be  restored  to  its  place, 
after  ensuring  good  asepsis.  Delorme  judiciously 
advises  that  all  splinters  of  bone  which  are  in  the 
least  adherent  should  be  left,  and  only  free  portions 
removed.  Further,  great  care  must  be  taken  in  the 
removal  of  splinters  and  the  cleansing  of  the  wound 
when  the  eye  is  still  present ;  we  shall  return  to  this 
later. 

It  should  be  remembered  that  fractures  of  the 
superior  orbital  margin  and  walls  are  less  serious  than 
those  of  the  superior  wall  alone.  De  Wecker  is  of 
opinion  that  when  the  vulnerant  force  has  broken 
both  the  margin  and  the  wall  the  shock  is  deadened 
and  reacts  less  seriously  on  the  brain.  It  is  also 
possible  that  fracture  of  the  margin  renders  the 
natural  drainage  more  efficacious  and  facilitates  the 
escape  of  the  septic  discharges  which  are  easily  retained 
in  a  narrow,  concealed  fracture  of  the  orbital  wall.  It 
is  certain  that  one  sees  such  fractures,  at  first  apparently 
not  serious,  terminate  rapidly  in  death.  Dupuytren 
has  already  noticed  under  these  circumstances  the  ap- 
parent benignity  of  the  external  wound,  and  amongst 


972  FRACTURES  OF  THE  ORBIT 

the  four  cases  of  this  kind  reported  by  Mackenzie 
there  is  one  in  a  subject  who,  wounded  by  a  sword 
in  tlie  left  orbit,  walked  two  leagues,  ate  with  good 
appetite,  feeling  no  pain,  and  then  died  the  next 
day  ;  nis  wound  had  penetrated  to  the  brain.  Rollet 
recalls  similar  cases  from  Diemerbroeck,  Gayet  and 
Arloing. 

Berlin  has  laid  great  stress  on  the  frequency  of 
these  rapid  deaths  after  fracture  of  the  roof  of  the  orbit, 
quoting  cases  of  immediate  death  due  to  the  rupture 
of  large  vessels ;  but  he  brings  especially  into  relief 
the  part  played  by  meningo -encephalitis,  which  appears 
from  the  third  to  the  sixth  day,  and  should  therefore 
be  borne  in  mind  by  the  surgeons  at  the  front  who 
are  charged  with  the  early  treatment. 

In  the  presence  of  such  injuries  the  surgeon  should 
examine  very  attentively  both  the  local  conditions  and 
the  general  state  of  the  patient,  and  regard  these  small 
orbito -palpebral  wounds  very  seriously  from  the  outset. 
As  soon  as  possible  he  should  endeavour  to  have  the 
subject  radiographed,  before  any  surgical  treatment 
has  been  adopted ;  but  if  this  preliminary  measure  is 
impossible  it  need  only  to  be  regretted  so  far  as 
concerns  the  possible  presence  of  a  foreign  body. 
Radiography,  unhappily,  will  give  no  information  as 
to  fractures  of  the  orbital  vault ;  fractures  in  them- 
selves extensive,  with  splinters  of  small  dimension, 
pass  unperceived ;  we  have  often  been  astonished  at 
the  impotence  of  X-rays  in  this  respect.  It  is,  how- 
ever, a  clinical  fact  which  must  be  accepted  and  made 
the  best  of. 

Hence  the  subject's  general  condition  and  the  cere- 
bral symptoms  should  be  the  basis  of  treatment.  If 
the  inflamed  wound  appears  soiled,  if  there  is  fever, 
prostration,  pains  in  the  head  and  so  on,  there  must 
be  no  hesitation  in  exploring  the  wound,  cleansing  the 
track  and  opening  it  up,  so  as  to  enable  the  discharges 
to  flow  away  freely. 


TREATMENT  OF  COMPLICATIONS  ^^3 


(b)  Fractures  of  the  Internal  Margin  and  Wall 

All  the  general  considerations  already  mentioned 
apply  to  these  fractures ;  so  far  as  they  are  specially 
concerned,  if  the  bones  are  smabhed  in,  some  attempt 
should  be  made  to  replace  the  fragments  in  good 
position.  Hippocrates  has  already  advised  that  the 
reduction  be  made  by  means  of  a  finger  introduced 
into  the  nostril ;  military  surgeons  have  used  an 
elastic  cannula  (Boyer)  or  a  metallic  tube  (Cf\rles 
Bell).  Rot.let,  after  Molieke  and  Chandelux, 
advises  replacing  the  fragments  witli  the  fingers  and 
rounded  instruments,  employing  an  esthesia  if  neces- 
sary, and  maintaining  the  fracture  in  position  by  a 
gutta-percha  appliance.  Later,  attention  must  be  paid 
to  the  state  of  the  lacrymal  passages,  which  are  usually 
obliterated,  and  attempts  must  be  made  to  re-establish 
their  permeability. 


(c)  Fractures  of  the  Inferior  Margin  and  Wall 

When  the  malar  bone  is  comminuted  and  driven  in 
it  will  sometimes  be  possible  to  elevate  the  fragments, 
replace  them,  and  so  reconstitute  the  prominence  of 
the  cheek.  ^  The  patient  thus  avoids  the  necessity  for 
a  later  reparative  operation.  This  elevation  of  the 
malar  bone  may  even  be  effected  a  long  time  after  the 
accident ;  Gayet  and  Cl.  Martin  (of  Lyons)  have 
succeeded  in  raising  the  malar  bone  and  fixing  it  in  its 
normal  situation  with  platinum  pins. 

When  the  case  first  receives  attention,  the  military 
surgeon  should  always  bear  in  mind  that  the  bones  of 
the  orbit  are  endowed  with  great  vitality;  not  only 
should  fragments  of  bone  which  possess  any  shred  of 
adhesion  not  be  removed,  but  it  is  advisable  to  replace 
completely  detached  bone  in^ood  position  and  graft 
the  splinters  in  their  no rmaL  situation,  covering  them 
with  the  soft  parts. 


974  FRACTURES  OF  THE  ORBIT 

(d)  Fractures  of  the  External  Margin  and  Wall 

The  same  rules  will  again  inspire  action  here ;  the 
external  orbital  arch,  if  it  is  fractured  and  thrust  in 
one  or  more  pieces  into  the  temporal  fossa,  must  be 
put  back  in  its  place  and  preserved  as  much  as  pos- 
sible. When  the  external  wall  is  involved,  the  fracture 
is  deeply  placed  at  the  bottom  of  a  ,thick  layer  of 
muscular  tissue  ;  there  must  be  no  timidity  in  incising 
soft  parts,  both  in  order  to  seek  splinters  and  foreign 
bodies  in  the  wound,  and  also  to  facilitate  the  escape 
of  discharge. 

Nearly  allied  to  these  isolated  fractures  of  the 
various  borders  and  walls  of  the  bony  framework  of  the 
orbit  are  the  comminuted  fractures  involving  several  of 
the  walls,  and  here  Larrey's  well-known  case  may  be 
recalled,  in  which  the  subject  was  struck  on  the  face 
by  a  cannon-ball  which  carried  away  the  whole  of  the 
lower  jaw,  the  bones  of  the  nose,  the  ethmoid,  the 
two  malar  bones,  and  the  zygomatic  arches.  In  gun- 
shot suicides,  when  the  weapon  is  placed  under  the 
chin,  the  authorities  in  forensic  medicine  have  fre- 
quently recorded  similar  disasters ;  the  niles  given  on 
the  subject  of  the  treatment  suitable  in  such  a  case 
follow  from  the  principles  and  the  special  rules  already 
referred  to.  The  clinical  instincts  of  the  surgeon  will 
here  have  full  play. 

To  indicate  with  more  detail  the  treatment  to  be 
followed  we  will  now  study  what  steps  should  be 
taken  at  the  outset  in  fractures  of  the  orbit  according 
as  :  (1)  the  eye  is  preserved ;  (2)  the  eye  is  destroyed ; 
(3)  the  neighbouring  cavities  are  implicated;  (4)  a 
foreign  body  is  or  is  not  retained. 

(1)  The  Eye  is  Preserved 

If  the  eye  is  preserved  it  is  necessary,  above  all,  to 
do  nothing  which  will  compromise  the  mobility  or  the 
vitality  of  the  globe. 

Thus,  as  has  been  said  above  (pp  872c^  seqq.)^  the  eye 


TREATMENT  OF  COMPLICATIONS  975 

is  very  often  proptosed  as  the  result  of  an  intra -orbital 
haemorrhage,  which  thrusts  it  forcibly  forwards  and 
will  not  allow  the  eyelids  to  cover  it.  It  will  be 
necessary  by  ni(ians  of  an  appropriate  dressing  simply 
to  close  down  the  eyelids  in  front  of  the  eye.  If  this 
cannot  be  done  it  will  be  well  to  reduce  the  exoph- 
thalmos by  cautious  aseptic  incisions,  made  in  the 
lower  part  of  the  orbit,  in  such  a  manner  as  not  to  injure 
the  muscles,  and  keeping  as  far  as  possible  away  from 
the  levator,  which  is  less  able  to  endure  the  trauma- 
tism of  the  scalpel  than  the  extrinsic  muscles  of  the 
globe.  Unless  the  ophthalmic  ganglion,  that  "little 
brain  of  the  eye,"  be  destroyed,  we  shall  always  be 
able  to  avoid  inflammatory  phenomena  of  the  cornea, 
and,  in  the  absence  of  lagophthalmos,  the  organ  of 
vision  is  easily  preserved. 

If  the  blood  clot  should  suppurate,  it  will  be  necessary 
to  lay  open  more  freely  and  drain  in  such  a  way  that 
the  pus  may  easily  escape ;  the  result  may  still  prove 
very  satisfactory. 

(2)  The  Eye  is  Destroyed 

If  the  eye  is  destroyed,  the  surgeon  is  relieved  of 
anxiety ;  when  the  scleral  wound  has  been  large  enough 
to  permit  a  free  escape  of  vitreous  body,  he  will 
enucleate  the  globe  without  hesitation.  Such  an  eye 
is  destined  to  become  nothing  more  than  a  danger- 
ous withered  stump,  often  painful,  ready  to  stir  up 
mischief ;  reserving  further  remarks  on  the  subject 
later,  we  may  say  here  that  such  a  globe  is  nothing 
but  an  enemy  to  the  other  eye,  and  consequently 
to  the  patient.  We  think  it  is  not  wise  to  be  con- 
tented with  evisceration.  Doubtless  it  is  quite  true 
that  a  carefully  performed  evisceration,  in  which 
absolutely  no  trace  of  the  uveal  tract  is  left  behind, 
presents  no  dangers ;  but  often,  in  the  unavoidable  haste 
imposed  upon  an  operator  at  the  front  by  the  multi- 
plicity of  his  duties,  this  evisceration  will  be  hurried, 
and  harmful  debris  of  the  choroid  or  ciliary  body  will 


976  FRACTURES  OF   THE  ORBIT 

be  left  in  the  scleral  sac.  Further,  evisceration  is 
accompanied  by  more  or  less  purulent  secretion  of 
considerable  duration.  A  classic  enucleation,  mthin 
Tenon's  capsule,  quite  according  to  rule,  cutting  the 
optic  nerve  level  with  the  eye,  is  the  operation  to  be 
chosen.  We  recommend  it  urgently  to  all  our  surgical 
colleagues  into  whose  hands  fractures  of  the  orbit  fall 
in  the  first  instance,  when  the  eye  has  been  crushed, 
torn,  or  simply  laid  widely  open  by  the  projectUe. 

The  eye  once  removed,  nothing  more  is  to  be  feared 
in  the  orbit,  if  after  the  operation  antiseptic  lavage 
is  used,  cleansing  the  orbital  cavit}  according  as  the 
degree  of  infection  requires. 

The  ophthalmic  surgeon  may  here  turn  to  good 
account  the  discussions  which  have  taken  place  con- 
cerning Carrel's  method ;  it  is  not  our  place,  nor  our 
pretention,  to  guide  those  who  are  worthy  to  wield  the 
scalpel.  We  say  simply  that,  in  such  circumstances, 
free  opening-up,  to  allow  liquids  to  escape,  free  ablu- 
tions with  hydrogen  peroxide,  and  daily  lavage  with 
7  per  1000  saline  solution,  are  the  means  which  we 
consider  at  the  same  time  necessary  and  sufficient  for 
success. 

(o)  Fractures  Implicating  the  Neighbouring 

Cavities 

A  problem  of  diagnosis  arises  here  which  is  not 
easy  to  solve.  Radiography  does  not  give  complete 
satisfaction  on  this  subject ;  a  fracture  of  the  orbital 
vault  is  passed  over  easily,  we  may  even  say  always 
escapes  unnoticed ;  we  are  in  this  respect  much  less 
fortunate  than  the  surgeons  who  deal  with  frac- 
tures of  the  limbs,  for  whom  radiograms  reveal 
the  smallest  crack;  and  it  will  be  necessary,  when 
dealing  with  a  serious  fracture  of  the  orbit  with  or 
without  loss  of  the  eyeball,  to  inquire  into  all  the 
ordinary  clinical  signs  of  extension  to  the  brain. 

When  the  projectile  has  to  a  great  extent  destroyed 
the  roof  of  the  orbit  and  penetrated  into  the  cerebral 


TREATMENT  OF  COMPLICATION fi  977 

cavity  one  must  not  expect  to  see  in  every  case  the 
evidences  of  mischief  burst  forth  immediately ;  they 
only  come  about  consecutive  to  orbital  infection, 
which  is  propagated  secondarily,  by  way  of  the  breach 
itself,  to  the  encephalic  mass.  This  is  what  took 
place  in  a  very  interesting  case  published  by  Morax 
in  his  report  of  Oct.  1915.  A  soldier,  wounded 
Sep.  27,  1915,  went  to  the  Lariboisiere  hospital,  Oct.  10, 
with  the  diagnosis  of  bullet  wounds  which  had  caused 
fracture  of  the  walls  of  the  orbit,  the  nasal  bones, 
and  the  anterior  margin  of  the  frontal,  with  rupture  of 
the  eyeball.  The  wound,  which  was  very  large,  had 
been  plugged  with  sterile  gauze,  and  there  was  neither 
suppuration  nor  fever.  On  Oct.  12  no  change  had 
taken  place  in  the  condition  of  the  wound ;  on  the 
evening  of  the  12th,  rise  of  temperature,  vomiting,  pains 
in  the  head;  Oct.  14,  pains  in  the  head,  great  stiff- 
ness of  the  neck  and  Kernig's  sign ;  lumbar  puncture 
yields  a  turbid  liquid;  the  17th,  death  with  signs  of 
acute  meningitis.  The  autopsy  showed  a  fracture 
implicating  the  anterior  floor  and  suppurative  inflam- 
mation between  the  dura  mater  and  the  right  frontal 
lobe. 

With  this  case  of  Morax's  we  might  compare 
Valude's,  wound  by  rifle  bullet  at  the  supero -external 
portion  of  the  right  frontal  bone,  with  escape  of 
cerebral  matter  by  the  frontal  wound ;  there  had 
been  an  abscess  of  the  eyelid  and  keratitis  with 
hypopyon.  All  seemed  to  be  going  well  until  ence- 
phalic infection  set  in,  and  the  patient  died.  (Report 
of  Jan.  1915.) 

With  these  should  be  compared  the  report,  quoted 
above,  of  a  case  in  which  the  patient  was  enabled 
to  recover,  thanks  to  an  operation  done,  late  enough 
it  is  true,  since  the  subject  already  presented  serious 
cerebral  symptoms,  but  as  quickly  as  possible ;  we 
performed  in  this  case  an  atypical  trephining  of  the 
cranium  by  the  orbital  route.     (Case  65.) 

Valude  was  also  fortunate  in  a  case  in  which 
radiography  showed  a  sub-cranial  bullet  beyond  the 


978  FRACTURES  OF  THE  ORBIT 

orbit.  Enucleation  had  been  performed,  but  the  pro- 
jectile, well  tolerated,  had  not  been  extracted ;  it 
soon  gave  rise  to  serious  symptoms  of  infection, 
oedema  of  the  eyelids,  and  chemosis ;  Valude  inter- 
fered, and  removed  the  offending  projectile  from  a 
depth  of  six  centimetres,  in  lardaceous  tissue ;  the 
patient  recovered.     (Report  of  April,  1915.) 

The  conclusion  of  these  remarks  is  that,  if  infectious 
orbital  and  para-orbital  phenomena  appear  after  a 
fracture,  the  offending  body  must  be  at  once  looked 
for ;  we  recommend  that  the  periosteum  of  the  orbital 
vault  be  detached  with  care,  because  of  the  thinness 
of  the  wall.  Also,  should  a  fracture  exist  which  the 
radiogram  does  not  show,  the  septic  fluids  may  escape 
by  way  of  the  orbit,  if  it  is  well  laid  open  and  thor- 
oughly cleansed.  If  in  the  course  of  the  operation  a 
fracture  of  the  vault  is  met  with,  the  roof  must  be 
trephined  and  a  free  communication  thus  established 
between  the  anterior  encephalic  region  and  the  orbital 
cavity.  In  short,  it  is  necessary  to  act  in  the  presence 
of  cranial  fractures  implicating  the  orbit  as  the  surgeon 
is  accustomed  to  act  in  fractures  of  the  cranium  in 
general.  At  the  first  sign  of  extension  to  the  ence- 
phalon,  or  if  it  is  suspected,  one  must  act  at  once. 

Moreover,  we  should  add  that  the  diagnosis  of  ence- 
phalic disorders  coinciding  with  fractures  of  the  orbit 
is  far  from  being  always  easy,  and  that  from  this 
point  of  view  we  may  meet  with  surprises,  the  more 
so  since  the  best  radiograms,  as  has  already  been  said, 
give  very  little  information  in  this  kind  of  bony 
disturbance.  We  shall  never  forget  the  cruel  mis- 
fortune which  happened  to  us  in  Case  66,  in  which  no 
encephalic  symptom  of  any  kind  appeared,  in  which 
radiography  showed  nothing  definite,  and  which  pre- 
sented, with  a  symblepharon  of  the  upper  eyelid,  a 
fairly  hard  intra -orbital  tumour,  slightly  resistant, 
which  we  believed  to  be  the  remains  of  the  eye, 
destroyed  by  the  injury.  We  set  about  removing  this 
debris  ;  at  the  first  stroke  of  the  scissors,  sero -purulent 
liquid  poured  out,  and  at  the  bottom  of  the  pouch 


TREATMENT  OF  COMPLICATIONS  979 

we  found  the  pulsatile  encephalic  mass ;  in  spite  of 
careful  antisepsis,  a  meningo -encephalitis  developed 
which  rapidly  carried  off  the  patient.  There  was 
nothing  to  warn  us  in  the  history  of  the  patient, 
wounded  a  long  time  previously,  nothing  in  the 
examination  of  his  radiogram,  or  in  any  of  his  symp- 
toms, to  suggest  that  there  might  be  free  communica- 
tion between  the  orbit  and  the  cranium. 

After  these  cases  of  orbital  fracture,  remarkable 
for  the  importance  of  their  intra-cranial  complications, 
it  will  be  well  to  cite  less  serious  cases,  in  which,  in 
spite  of  evidence  of  cerebral  disorders,  infectious  acci- 
dents being  absent,  it  has  not  been  necessary  for  the 
surgeon  to  interfere.  We  have  noted  cases  in  which 
the  orbital  fracture  was  accompanied  only  by  optic 
neuritis,  vertigo  and  anaesthesia  of  the  face  with 
intermittent  headache. 

In  one  case,  after  injury  by  a  large  piece  of  shell, 
lodged  behind  the  left  zygomatic  process  and  the  pro- 
cess of  the  mandible,  there  was  escape  of  cerebral  matter 
from  the  wound,  and  there  occurred  neuritis  (choked 
disc)  and  epileptiform  attacks  which  did  not  appear  to 
warrant  fresh  interference  (see  Case  63). 

After  the  fractures  of  the  orbit  implicating  the 
cranial  cavity,  let  us  consider  for  a  moment  those 
which  concern  the  maxillary  and  frontal  sinuses. 
These  are  infinitely  less  serious ;  two  classes  of  cases 
must  be  distinguished:  (1)  those  in  which  the  lesion 
of  the  sinus  is  accompanied  by  the  presence  of  a  pro- 
jectile ;  (2)  those  in  which  there  exists  simply  a 
sinusitis  without  retained  projectile. 

When  a  projectile  is  present  it  should  be  extracted 
without  delay.  Nothing  is  simpler ;  we  will  not  quote 
all  the  cases  in  which  we  have  been  able  to  interfere 
under  such  conditions  :  it  will  be  sufficient  to  recall 
here  the  cases  quoted  above  (pp.949  et  seqq.),  and  to 
note  amongst  the  foreign  bodies  we  have  found  in  the 
sinus  the  eye  itself,  luxated  by  the  traumatism  and 
thrust  through  the  fracture  in  the  floor  of  the  orbit 
into  the  antrum. 


980  FRACTURES  OF  THE  ORBIT 

The  frontal  sinus  is  less  frequently  injured  than  the 
antrum,  and  we  have  never  found  a  foreign  body  in 
this  cavity,  but  it  is  sometimes  implicated  by  a  projec- 
tile which  ruptures  its  anterior  wall,  in  such  a  manner 
that  an  unsightly  depression  results.  In  several  cases 
of  this  kind,  we  have  been  able  to  fill  up  the  cavity 
by  the  aid  of  an  adipose  graft,  which  has  given  a 
satisfactory  result  (see  pp.    957  et  seqq.). 

In  another  case,  quite  analogous  to  these,  and  re- 
markable for  destruction  of  the  pulley  of  the  superior 
oblique,  the  patient  refused  to  have  an  adipose  graft, 
which  appeared  to  us  under  such  circumstances  highly 
desirable.  We  shall  return  later  to  this  type  of  in- 
tervention, publishing  some  successful  cases  from  our 
practice. 

(4)  Presence  of  a  Foreign  Body 

When  there  is  a  foreign  body  in  the  orbit  or  in  the 
neighbouring  cavities  it  is  not  always  necessary  to 
extract  it ;  it  is  certain  that  very  often  these  foreign 
bodies,  quite  aseptic  and  fortunately  situated,  may  be 
well  tolerated.  When  they  are  situated  in  the  cranial 
cavity  they  merit  particular  respect  if  they  are  giving 
no  trouble ;  it  is  precisely  the  type  of  case  in  which 
the  practitioner  should  rely  upon  his  clinical  sagacity. 
When  the  foreign  body  is  in  the  orbit  or  in  the  maxil- 
lary antrum  the  surgeon's  perplexity  becomes  much 
less ;  a  priori  it  should  be  removed,  however  small  it 
may  be. 

To  remove  a  foreign  body,  weU  localised  by  radio- 
graphy, from  the  maxillary  sinus  it  is  well  to  use 
the  aperture  made  by  the  projectile  if  it  is  well 
in  evidence ;  if  not,  open  out  the  anterior  wall  of 
the  sinus  without  hesitation,  taking  care  of  the  infra- 
orbital nerve ;  the  foreign  body  may  be  easily  picked 
out  of  the  sinus,  which  at  the  same  time  should  be 
thoroughly  cleansed  and  drained  by  the  side  of  the  nose. 

When  the  foreign  body  is  in  the  orbit  two  conditions 
must  be  distinguished,  according  as  the  eye  is  preserved 


TREATMENT  OF  COMPLICATIONS 


981 


or  destroyed.  When  it  is  destroyed  nothing  is  simpler 
than  to  take  hold  of  the  foreign  body  by  means  of 
ordinary  instruments,  sparing  as  much  as  possible 
everything  which  is  of  importance  for  a  good  prothesis, 
especially  the  levator  muscle  of  the  eyelid.  When  the 
eye  is  intact,  at  least  in  appearance,  it  is  indispensable 
to  remove  the  foreign  body  without  disturbing  the  eye. 
If  the  foreign  body  is  in  the  anterior  region  of  the 
orbit  an  incision  of  the  soft  parts  will  often  suffice  to 


Fig.  64. 

give  the  surgeon  access  to  it.  For  the  search,  help  is 
obtained  of  the  electro -magnet  and  all  the  means  of 
extraction  in  use  in  ordinary  surgery ;  but  when  the 
foreign  body  is  retrobulbar  and  deeply  buried,  there 
must  be  no  hesitation  in  having  recourse  to  Kronlein's 
operation,  which  we  have  no  need  to  describe  here,  and 
which  Fig.  64  will  adequately  recall  to  our  readers. 

When  the  foreign  body  is  situated  on  the  ethmoid 
side,  in  the  internal  region  of  the  orbit,  we  recommend 
the  operative  procedure  we  have  elsewhere  advised 
for  the  ablation  of  certain  orbital  tumours  placed  to  the 
inner  side  of  the  optic  nerve.    It  is  an  advantage  in  this 


982 


FRACTURES  OF  THE  ORBIT 


case  to  mobilise  Kronlein's  flap,  in  order  to  be  able  to 
throw  the  eye  outwards  towards  the  external  wall  of  the 
enlarged  orbit  (Fig.  65) ;  by  this  device  one  has  room 
to  operate  and  the  ophthalmic  ganglion  is  not  touched, 


Fig.  65. 


a  most  important  organ  to  be  considered  when  it  is 
desired  to  preserve  the  eyeball  intact. 

The  reader  will  have  already  found  in  this  work  re- 
ports of  cases  in  which  Kronlein's  operation  has  been 
performed  with  extremely  favourable  results  (see  pp. 
844  e^  seqq.). 


CHAPTER    VII 

TREATMENT  OF   OCULAR  COMPLICATIONS 

The  principal  ocular  complications  which  merit  our 
attention  are  — 

(1)  Sympathetic  ophthalmia. 

(2)  Traumatic  cataract. 

(3)  Detachment  of  the  retina. 

(1)  Sympathetic  Ophthalmia 

Projectiles  of  war  fracturing  the  orbit  often  involve 
the  eyeball,  either  by  penetrating  into  its  interior  or 
by  rupturing  its  envelope  and  so  destroying  it.  To 
our  great  surprise,  as  we  have  said  elsewhere  (p.  891) 
we  have  not  met  with  a  single  case  of  partial  rupture 
of  the  sclerotic,  permitting  the  eye  to  survive  and  to 
keep  its  appearance  after  such  an  injury. 

When  the  eye  is  implicated  to  this  degree  by  the 
projectile  its  shape  is  destroyed,  the  greater  part  of 
the  vitreous  body  is  expelled,  and  the  surgeon  is 
immediately  faced  with  a  stump  more  or  les^  large, 
more  or  less  inflamed,  more  or  less  torn,  and  whose 
future  is  the  cause  of  great  anxiety. 

Two  questions  here  present  themselves  : — 

(1)  What  should  be  done  with  an  eye  which  has  a 
foreign  body  in  its  interior  ? 

(2)  What  should  be  done  with  an  eye  whose  mem- 
branes are  ruptured,  and  which,  without  a  retained 
foreign  body,  has  at  the  same  time  absolutely  lost  its 
outward  appearance,  and  also  its  visual  power  irre- 
mediably ? 

These  two  questions  are  serious  because  they  involve 

983 


984  FRACTURES  OF   THE  ORBIT 

that  subject,  so  distressing  and  still  so  much  discussed 
by  surgeons,  sympathetic  ophthalmia. 

Sympathetic  ophthalmia  has  not  been  dreaded  to 
the  same  degree  by  all  ophthalmic  surgeons ;  there 
are  those  who  do  not  believe  in  it,  who  declare  they 
have  never  seen  it  (Poularl  There  are  others,  and 
we  are  of  the  number,  who,  without  considering  it  fre- 
quent, think  it  is  not  so  rare  that  we  may  put  it  out 
of  our  thoughts  altogether. 

On  the  subject  of  its  frequency  in  military  surgery, 
we  shall  take  as  a  basis  abstracts  from  the  reports  of 
the  ophthalmic  centres  which  have  been  published 
during  the  past  two  years  by  our  colleagues  in  the  army. 
We  find  there  the  following  evidence. 

Kalt  (Report  of  Oct.,  1915),  is  astonished  at  not 
having  met  with  a  single  case,  in  spite  of  the  number  of 
atrophied  globes  which  he  has  seen  as  a  sequel  of 
penetrating  wounds,  and  it  seems,  he  says,  that  there 
is  here  a  discordance  with  what  we  observe  in  civil 
practice  ;  but  it  does  not  happen  that  all  our  colleagues 
have  made  such  a  remark.  CossE  (Dec,  1914)  cites 
two  cases,  one  of  which  terminated  in  blindness,  and 
he  notes  a  third  grave  case  in  April,  1915.  Coutela 
(Report  of  June,  1915)  relates  a  case  occurring  seven- 
teen days  after  enucleation,  and  two  more  in  his  Report 
of  the  following  month ;  these  cases,  relatively  benign 
(the  attenuated  ophthalmia  of  De  Lapersonne) 
recovered,  but  they  presented  real  gravity.  We  must 
therefore  resort  to  enucleation  neither  too  much  nor  too 
little,  says  Coutela.  Terrien  holds  a  similar  opinion  ; 
he  has  performed,  in  order  to  prevent  sympathetic 
ophthalmia,  a  relatively  large  number  of  enucleations 
and  optico -ciliary  neurotomies. 

Among  the  cases  of  sympathetic  ophthalmia  published 
by  the  directors  of  the  centres  of  military  ophthal- 
mology we  should  especially  mention  a  case-report  pub- 
lished by  Teulieres  (Report  of  Feb.,  1916)  concerning 
a  simple  contusion  of  the  eye  without  foreign  body  and 
without  wound  ;  enucleation  of  the  atrophied  stump  on 
the  1  ight  side  controlled  the  affection  whose  sympathetic 


TREATMENT  OF  OCULAR  COMPLICATION      985 

origin  was  thus  well  established.  Such  cases  are  so 
rare  that  it  is  perhaps  permissible  to  believe  that  there 
existed  a  small  conjunctival  wound,  which  passed 
undetected  before  the  patient  was  submitted  to  the 
examination  of  our  colleague. 

To  these  cases  we  shall  add  the  very  interesting  one 
reported  by  Mo  rax  in  June,  1916;  it  was  a  question 
of  an  operation  for  traumatic  cataract ;  a  prolapse  of 
the  iris  had  occurred  which  had  been  cauterised.  Sym- 
pathetic ophthalmia  resulted,  not,  to  define  it  exactly, 
from  the  extraction  of  the  lens,  but  from  faulty  cica- 
trisation after  the  latter  operation. 

Such  is  a  rapid  enumeration  of  the  principal  cases 
published  during  this  war  in  the  reports  of  our  collea- 
gues ;  doubtless  others,  in  considerable  numbers,  have 
not  been  mentioned  ;  we  have  a  proof  of  the  frequency 
of  accidents  of  sympathetic  origin  in  the  work  just 
published  by  Dr.  Cousin,  aide-major  attache  au  centre 
de  \p  9^  Region  ;  this  author  gives  sixteen  cases  in  which 
he  has  found  sympathetic  reactions  following  injuries 
of  war ;  these  sympathetic  reactions  are  not  ophthalmia, 
since  after  all  there  is  no  inflammation,  no  serous  iritis 
as  in  attenuated  sympathetic  ophthalmia ;  but  we  say 
without  hesitation  that  photophobia,  lacrymation, 
fatigue  in  reading,  and  diminution  of  visual  acuity,  are 
the  first  degree  of  the  affection,  of  which  serous  iritis 
is  the  second  degree  and  of  which  irido-cyclitis  is  the 
third.  All  this  pertains  to  sympathetic  ophthalmia, 
and  it  is  a  misfortune  if  a  patient,  thus  attacked,  is 
under  the  care  of  an  operator  capable  of  hesitating  and 
putting  off  the  enucleation. 

In  our  centre  of  military  ophthalmology  we  have  also 
met  with  cases  of  sympathetic  ophthalmia  amongst  the 
cases  sent  to  us ;  we  shall  not  report  them  in  detail 
in  order  not  to  overweight  this  chapter,  which  must  be 
short. 

Out  of  2554  injuries  involving  the  eyeball  we  have 
seen  five  cases  of  sympathetic  ophthalmia.  In  the 
first  four  cases  it  was  a  matter  of  a  perforating  wound 
of  one  of  the  globes  in  the  ciliary  region,  with  presence 


986  FRACTURES  OF  THE  ORBIT 

of  an  intra-ocular  foreign  body.  Sympathetic  irido- 
cyclitis made  its  appearance  on  one  occasion  fourteen 
days  after  the  traumatism  ;  in  the  next  case,  forty  ;  in 
the  third  case,  nineteen ;  in  the  fourth  case,  thirty -two 
days  after  the  injury. 

In  these  four  cases,  prompt  enucleation  at  the  outset 
brought  about  complete  recovery  in  three ;  the  fourth 
had  a  relapse  which  yielded  to  treatment. 

The  fifth  case  was  that  of  a  soldier,  wounded  on 
Oct.  11,  1915,  upon  whom  Dr.  Lataillade  performed 
evisceration  of  the  right  eye  for  panophthalmitis  fol- 
lowing a  perforating  wound,  and  which,  on  Nov.  7,  1915, 
presented  optic  neuritis  of  the  left  side,  probably  of 
sympathetic  nature. 

Enucleation  of  the  right  stump  and  its  dissection 
revealed  a  small  fragment  lodged  in  the  scleral  envelope 
in  contact  with  the  optic  nerve.  Improvement  of  the 
neuritis  followed  very  rapidly.  The  case  has  been, 
moreover,  reported  above. 

What,  therefore,  is  the  course  to  take — 

(1)  In  the  case  where  the  injured  eyeball  contains 
a  foreign  body  ? 

(2)  In  the  case  where  there  is  an  eye,  without  a 
foreign  body,  but  profoundly  damaged,  completely 
deprived  of  sight,  after  an  open  wound  ? 

We  expounded  our  views  on  the  subject  of  the 
first  case  at  the  meeting  of  the  Societe  frangaise 
d'Ophtalmologie,  April,   1916. 

If  the  eye  containing  a  foreign  body  has  still  useful 
vision  it  should  be  spared. 

When  it  no  longer  has  vision  two  classes  of  conditions 
must  be  considered  : — 

(1)  The  foreign  body  is  in  the  ciliary  region. 

(2)  The  foreign  body  is  in  the  eye,  but  outside  the 
ciliary  region. 

If  the  foreign  body  is  in  the  ciliary  region  of  an  eye 
deprived  of  vision,  however  good  may  be  the  appearance 
of  the  eye,  even  when  the  patient  complains  of  no  pain 
and  no  symptom  of  irritation  it  is  necessary  to  enucleate 
the  eye. 


TREATMENT  OF  OCULAR  COMPLICATIONS    987 

If  the  foreign  body  is  not  in  the  ciliary  region  and  the 
eye  is  quite  intact,  neither  irritable,  nor  painful,  nor 
reduced  in  tension,  the  eye  should  be  spared,  at  the 
same  time  warning  the  patient  that,  in  the  future, 
things  may  not  always  go  so  well. 

If,  on  the  contrary,  the  eye  containing  the  foreign 
body  elsewhere  than  in  the  ciliary  region  is  reduced 
in  tension,  a  little  tender  on  pressure,  if  its  nutrition 
is  visibly  suffering,  it  should  be  enucleated  without 
delay,  and  not  be  allowed  to  leave  the  other  eye  in  such 
a  dangerous  neighbourhood. 

These  are  the  rules  which  I  should  like  to  see  officially 
recommended  to  surgeons  who,  without  being  ophthal- 
mological  specialists,  are  often  forced  by  circumstances 
to  treat  wounds  of  the  eye ;  and  also  to  the  younger 
ophthalmic  surgeons,  who  are  not  yet  fully  experienced. 

It  is  expedient  that  everybody  should  be  able,  in  the 
case  of  intra-ocular  foreign  body,  to  do  an  enucleation 
at  the  fitting  time ;  and,  in  my  opinion,  the  time  has 
come  to  formulate  general  practical  rules  which  can  be 
utilised  in  everyday  clinical  work. 

The  same  rules  are  applicable  to  the  second  class 
of  conditions.  If  the  eye  has  still  a  satisfactory 
appearance,  if  its  volume  has  been  almost  completely 
preserved,  its  diminution  of  tension  moderate,  its 
ciliary  region  insensitive  to  the  touch,  then  it  may  be 
kept.  But  when  it  is  the  seat  of  a  manifest  cyclitis, 
of  long  standing,  with  evident  inflammatory  reaction, 
however  slight  this  latter  may  be,  and  having  resisted 
appropriate  treatment  for  several  months,  one  must 
not  hesitate  to  consider  the  eye  dangerous  ;  much  more 
so  when  in  presence  of  an  atrophied  stump  resulting 
from  an  open  wound. 

In  this  question  of  the  treatment  of  sympathetic 
ophthalmia  and  with  the  views  which  we  have  laid 
down  we  take  our  stand,  therefore,  on  the  side  of  the 
enucleators.  Enucleation  of  the  globe  renders  great 
service  with  a  minimum  of  inconvenience,  and,  in  fact, 
the  horror  which  certain  of  our  confreres  have  of  this 
operation  makes  us  think  of  the  ostracism  with  which 


988  FRACTURES  OF  THE  ORBIT 

the  Athenians  sentenced  Aristides  because  they  were 
weary  of  hearing  him  called  "  the  Just." 

(2)  Traumatic  Cataract 

Amongst  the  complications  of  fractures  of  the  orbit 
which  may  arise  in  the  visual  apparatus  it  will  be 
well  to  give  a  place  to  the  injuries  which  bring  about 
luxations  or  cataracts. 

Here  we  shall  be  brief,  because  it  is  a  subject  which 
specially  belongs  to  injuries  of  the  eyeball  alone ;  in 
fractures  of  the  orbit  lesions  of  the  lens  subject  to 
ophthalmic  surgery  are  relatively  rare. 

The  first  question  which  arises  is,  to  know  when  to 
operate  and  when  not  to  operate  on  traumatic  cataracts 
in  military  surgery. 

Our  reply  is  ready  :  we  must  operate  on  these 
cataracts  on  the  same  principle  that  we  operate  upon 
cataracts  occurring  from  industrial  accidents  in  civil 
life.  In  restoring  sight  to  a  wounded  man,  we  are 
useful  at  the  same  time  to  the  patient  and  to  the 
employer,  and  there  is  no  reason  for  acting  otherwise 
when  the  patient  is  a  soldier  and  the  employer  is  the 
Motherland. 

The  advantages  to  the  patient  are  the  enlargement 
of  his  visual  field,  the  maintenance  of  the  eye  in  its 
normal  position,  and  finally  the  certitude,  when  the 
operation  has  had  a  fortunate  result,  that  sight  will 
be  always  preserved,  whatever  happens  to  the  other 
eye. 

To  the  State,  the  advantage  is  very  considerable ; 
these  cases  are  no  longer  "  reformes  no.  1  "  (discharged 
in  the  first  class)  from  the  moment  when  the  eye 
operated  upon  has  a  vision  equal  to  1/20 ;  the  soldier 
escapes  the  law  of  1831,  and  falls  under  the  Decree  of 
March  24,  1915,  which  provides  for  a  gratuity  propor- 
tional to  the  lessening  of  visual  acuity.  Instead  of  a 
pension  of  600  francs,  a  fairly  large  sum  for  the  loss  of 
vision  of  a  single  eye,  the  subject  of  aphakia  receives 
200  francs,  which  we  consider  ample,  and  moreover  it  is 


TREATMENT  OF  OCULAR  COMPLICATIONS    989 

in  conformity  with  the  tariff  of  the  law  of  April  9,  1898, 
concerning  occupational  accidents  ;  the  resultant  saving 
to  the  State  is  very  great,  and  deserves  to  be  borne  in 
mind  in  a  quite  exceptional  manner. 

Confronted  with  the  statistics  which  have  been 
published  by  a  large  number  of  ophthalmologists  it  is 
not  possible  seriously  to  maintain  that  intervention 
in  traumatic  cataracts  yields  no  results.  It  is  a  ques- 
tion simply  of  doing  it  at  the  right  time,  when  it  is 
indicated  ;  that  is  to  say,  it  is  only  necessary  to  interfere 
in  an  early  stage  for  glaucomatous  accidents  due  to 
swelling  of  the  ^'^^.y^  and,  apart  from  these  accidents,  to 
operate  only  on  cases  which  are  quite  settled  down, 
of  long  standing,  and  in  which  one  has  good  reports  as 
to  the  state  of  the  deep  membranes. 

As  a  general  rule,  we  operate  on  uncomplicated 
traumatic  cataracts  six  to  twelve  months  after  the 
injury.  When  the  lens  remains  entire,  a  large  incision 
in  the  cornea,  without  or  with  iridectomy,  permits  the 
evacuation  of  the  debris,  which  lavage  of  the  anterior 
chamber  by  the  aid  of  Chibret's  syringe  satisfactorily 
completes. 

If  only  a  more  or  less  thick  membrane  remains,  wc 
look  upon  the  various  methods  of  discission  with  needle 
or  sickle-knife  as  evil  interference,  and  as  still  worse, 
detachment  of  the  capsule  with  forceps,  so  unfortu- 
nately advised  by  Panas  ;  in  this  method  one  drags 
on  the  ciliary  processes,  perhaps  reviving  an  extinct 
irido-cyclitis  and  compromising  the  future  of  the  globe. 
Perhaps  it  is  to  this  error  of  technique  that  one  may 
look  for  the  cause  of  the  disappointments  mentioned 
by  some  colleagues.  The  operation  of  choice  in  such 
a  case  is  De  Wecker's  irido-capsulotomy ;  through  a 
small  subconjunctival  scleral  incision,  two  or  three 
millimetres  from  the  limbus,  the  thickest  portions  of 
membrane  are  divided  with  De  Wecker"s  scissors 
with  the  minimum  of  traumatism  and  without  loss  of 
vitreous. 

We  may  quote  here  our  results  obtained  in  our 
"  Service  central  d'Ophtalmologie  militaire." 


990 


FRACTURES  OF  THE  ORBIT 


TraiimaUc  Cataracts 

1.  Traumatic  cataracts  observed  =  175. 

Complicated 

Uncomplicated 

2.  Number  of  operations  =73. 

Extraction  with  or  without  iridectomy 
Irido-capsulotomy 


116 
59 

52 
21 


Results 


(a)   Acuity   superior   to 
1/20  =  37 


{b)  Acuity  inferior  to 


1/15 
1/10 
2/10 
3/10 
4/10 
5/10 
6/10 

1/20 


( Intra-ocular  foreign  body 
(c)  Acuity  nil  =  11  -  Haemorrhage  into  vitreous . 
[  Post-operative  irido-cyclitis 


8 
6 
6 
9 
2 
5 
1 

25 

3 
5 
3 


(3)  Retinal  Detachment 

The  treatment  of  traumatic  detachment  does  not 
differ  from  that  of  detachments  in  general. 

Iridectomy,  opotherapic  injections  into  the  vitreous 
body,  removal  by  puncture  of  the  sub-retinal  fluid, 
and  its  replacement  by  sclerosing  liquids  (tincture  of 
iodine),  and  electrolysis  are  not  procedures  to  be  re- 
commended, for  they  provoke  a  new  traumatism, 
serious  to  an  eye  already  irritated,  and  risk  arousing 
inflammatory  phenomena  which  may  result  in  the 
disorganisation  of  the  ocular  media  and  a  consecutive 
phthisis  of  the  globe. 

Amongst  the  various  procedures  for  treatment  of 
detachment  of  the  retina  there  is  one  which  for  several 
years  we  have  been  particularly  able  to  recommend, 
and  which  is  our  choice  ;  it  consists  in  creating,  in  the 


TREATMENT  OF  OCULAR  COMPLICATIONS    991 

region  of  the  canal  of  Schlemm,  beneath  the  conjunctiva, 
cicatricial  tissue  obliterating  the  filtration  spaces.  We 
have  termed  it  "  colmatage,"  an  operation  which 
consists  in  dissecting  up  the  whole  of  the  conjunctiva 
of  the  intercalary  region  between  the  insertion  of  the 
recti  muscles  and  the  cornea  ;  thus  dissected  up,  the  con- 
junctiva is  flattened  down  upon  the  cornea,  the  whole 
of  the  region  of  the  canal  of  Schlemm,  up  to  5  mm. 
behind  it,  is  cauterised,  and  the  mucous  membrane 
put  back  in  place  and  sutured.  The  newly  formed 
connective  tissue,  under  the  influence  of  cauterisation, 
obliterates  all  the  lymphatic  spaces ;  the  result  is  a 
kind  of  experimental  glaucoma. 

We  have  not,  however,  had  to  employ  this  procedure 
of  "  colmatage  "  on  our  patients,  because  it  is  indicated 
solely  in  hypotonic,  relaxed  eyes — a  frequent  symptom 
in  myopic  detachments,  which  have  a  physiognomy 
peculiar  to  themselves,  but  rare,  very  rare  indeed 
amongst  traumatic  detachments. 

The  result  is,  that  we  are  ourselves  content  with  the 
classic  treatment  by  subconjunctival  injections  of 
chloride  of  sodium,  the  instillation  of  atropine  combined 
with  compression  of  the  eye,  and  finally  prolonged 
decubitus  in  the  dorsal  position. 

This  line  of  treatment  gives  the  most  satisfactory 
results. 

Do  not,  however,  let  us  forget  that  time  is  the  princi- 
pal factor  in  the  cure  of  this  clinical  entity.  It  is 
incontestable,  in  fact,  that  prognosis,  while  sombre, 
is  much  more  favourable  than  for  the  myopic  and 
symptomatic  forms  of  a  general  affection.  Sometimes 
the  disappearance  and  more  often  the  diminution  of 
the  traumatic  detachment  comes  about  in  a  certain 
number  of  cases  at  the  end  of  a  lapse  of  time,  varying 
between  five  and  six  months. 

Out  of  135  cases  of  detachment  with  or  without 
orbital  fracture,  we  have  observed  three  cases  of  com- 
plete recovery.  There  remain  in  place  of  the  detach- 
ment, cicatrices  in  form  of  striae,  of  whitish  coloration. 
The  first  case  was  a  man  wounded  on  Oct.  28,  1914,  with 


992  FRACTURES  OF  THE  ORBIT 

a. contusion  of  the  orbital  right  margin,  "s^dth  scleral 
wound  and  a  large  retinal  detachment  at  the  infero- 
external  portion ;  this  detachment  still  persisted  on 
Feb.  28,  1915.  Dr.  Cantonnet,  called  later  to  re- 
examine the  case,  noted  the  complete  disappearance 
of  the  lesion,  and  we  ourselves  on  Oct.  30,  1915,  con- 
firmed the  complete  recovery.  The  second  was  de- 
scribed in  Case -report  2.  The  third  patient,  with  a 
detachment  at  the  infero -external  portion  of  the  left 
eye,  after  contusion,  was  well  seven  months  after  the 
traumatism.. 

Associated  with  these  repositions  of  the  retinal 
displacement,  we  have  noted  eight  cases  of  marked 
amelioration  in  the  extent  of  the  lesion,  in  the  raising 
of  acuity  and  in  the  enlargement  of  the  visual  field. 
The  proportion  of  these  favourable  results  is,  as  one 
sees,  restricted.  To  sum  up,  in  2-2  per  cent,  there  was 
recovery  from  the  detachment,  and  in  5' 92  per  cent, 
simple  amelioration.  It  is  well  always  to  be  on  one's 
guard  concerning  the  acuity  admitted  by  patients,  for 
it  is  certain  that  many  of  them  are  but  little  disposed 
to  make  known  their  true  visual  acuity.  After  the 
war,  when  the  wounded  men  are  no  longer  prompted  by 
the  hope  of  a  gratuity  or  a  discharge  we  shall  know  the 
truth  better. 


CHAPTER  VIII 

REPARATIVE   SURGERY   OF   ORBITAL 
FRACTURES 

In  presence  of  the  g'sat  destruction  of  the  soft  parts 
which  very  often  accompanies  fractures  of  the  orbit, 
the  malar  bone  crushed  in,  orbital  arches  broken, 
eyelids  lacerated  or  torn  to  ribbons,  the  surgeon  must 
consider  how  to  repair  these  damages  and  restore  to 
the  wounded  man  an  appearance  as  pleasing  as  cir- 
cumstances admit. 

Three  dominating  principles  will  be  before  his  mind  : 

(1)  To  replace  the  eyelids  in  position  and  restore 
their  normal  form  as  closely  as  possible. 

(2)  To  restore  if  possible,  and  very  often  it  has 
been  possible,  the  conjunctival  culs-de-sac,  so  as  to 
retain  an  artificial  eye. 

(3)  To  re-establish,  so  far  as  may  be,  the  exterior 
form  of  the  orbit,  by  filling  up  gaps  in  the  bone  by 
suitable  grafts. 

(A)  Restoration  of, the  Eyelids 

It  is  unnecessary  to  write  the  history  of  blepharo- 
plasty  here.  It  is  contained  in  all  the  textbooks,  and 
quite  recently  it  has  been  excellently  retold  by  our 
colleague  Magitot  in  the  Reports  of  the  Societe 
d'Ophtalmologie  de  Paris,  July  1916. 

We  prefer  the  Indian  method,  as  he  does,  and  the 
short  pedicle  has  always  sufficed  for  our  patients  in 
the  numerous  cases  in  which  we  have  had  to  interfere. 
We  have  most  often  used  the  frontal  flap,  and  when 
we  have  had  both  eyelids  to  restore,  we  have  fashioned 
a  frontal  flap  and  a  malar  flap  at  the  same  time. 

993 


994 


FRACTURES  OF  THE  ORBIT 


We  always  found  it  possible  to  remake  suitable 
eyelids,  and  we  could  quote  here  a  large  number  of 
satisfactory  results;  it  seems  to  us  that  they  do  not 
greatly  differ  from  those  which  have  been  obtained 
by  our  colleagues  in  military  surgery,  and  we  do  not 
dwell  on  the  point  (Figs.  66  and  67). 


Fig.  66. 

(B)  Restoration  of  the  Conjunctival  Culs-de-sac 

The  restoration  of  the  culs-de-sac  is  a  very  interesting 
question,  one  of  the  most  difficult  in  ophthalmic  surgery, 
but  we  think  it  is  a  subject  upon  which  we  must  not 
expatiate,  as  it  is  only  indirectly  connected  with  that 
of  orbital  fractures  by  projectiles  of  war. 

We  will  simply  remind  our  readers  that  the  essential 
condition  for  efficient  action  is  to  add  to  the  portion  of 


REPARATIVE  SURGERY 


995 


conjunctiva  which  has  been  preserved  a  tissue  capable 
of  replacing  the  destroyed  mucous  membrane.  To 
obtain  it,  some  prefer  a  dermo-epidermic  graft  (Franck, 
Weeks),  others  a  graft  limited  to  the  epidermis  (Ma- 
gitot)  ;  the  latter  author  dissects  up  from  a  part  dis- 
tant from  the  eye,  the  thigh  for  example,  an  epidermic 


Fig.  67. 


flap  with  which  he  covers  a  piece  of  metal  introduced 
into  the  orbital  cavity  in  such  a  manner  that  the  raw 
surface  of  the  flap  is  applied  to  the  refreshed  surface 
of  the  inner  aspect  of  the  eyelids.  We  have  had 
no  experience  of  this  latter  procedure.  We  have 
several  times  made  use  of  that  of  Franck,  with  un- 
satisfactory results,  and  that  is  a  sufficient  reason  for 
trying  another  method. 


996  FRACTURES  OF   THE  ORBIT 

With  our  military  patients  we  have  been  contented 
with  restoring  the  culs-de-sac  with  Snellen's  sutures, 
of  which  we  have  made  large  use  with  great  success, 
varying  the  form  and  the  situation  according  to  the 
individual  case.  We  do  not  include  the  inferior  cul- 
de-sac,  which  is  often  the  more  at  fault  and  also  the 
more  important.  We  have  enlarged,  deepened,  or  even 
made  it  anew  by  splitting  the  eyelid,  as  Truc  indicates 
in  his  procedure  en  vanne,  drawing  the  internal  half 
of  this  eyelid  forcibly  downward  by  the  aid  of  one  or 
two  sutures.  The  cul-de-sac  does  not  remain  as  well- 
marked  as  at  first,  but  a  sulcus  deep  enough  to  retain 
an  artificial  eye  constantly  persists.  We  also  believe 
that  lining  the  lower  eyelid  with  a  morsel  of  skin 
borrowed  from  the  temple  (Snellen),  the  cheek  (Har- 
lan), or  the  Upper  eyelid  (Samelsohn)  is  worthy 
of  recommendation. 

In  addition  we  have  recourse  to  artificial  dilatation 
by  pieces  of  rubber  in  graduated  sizes,  inserting  suc- 
cessively larger  and  larger  pieces,  following  the  advice 
given  on  this  subject  b}^  Dr.  Coulomb,  and  we  have 
had  the  satisfaction  of  rendering  habitable  a  large 
number  of  sockets  which  at  first  seemed  as  ill-disposed 
as  possible  towards  receiving  a  prothe^is. 

We  do  not  dwell  upon  this  question,  for,  like  that 
of  blepharoplasty,  it  is  on  the  fringe  of  the  subject, 
and  does  not  belong,  strictly  speaking,  to  fractures  of 
the  orbit. 

W^e  hasten  to  discuss  what  dominates  the  reparative 
surgery  of  these  fractures,  namely,  the  treatment  of 
loss  of  substance  of  the  bony  foundation  and  the  re- 
establishment  of  the  regular  contour  of  the  orbit. 
That  is  indeed  the  heart  of  the  subject.  The  restora- 
tion of  the  eyelids  and  of  the  conjunctival  sac  have 
little  to  do  with  orbital  fractures,  and  such  matters  as 
transplantation  of  labial  mucous  membrance  (Cardo, 
Sizoreff),  the  employment  of  the  skin  and  cartilage  of 
the  ear  (Budinger),  etc.,  are  scarcely  germane  to'the 
subject. 


REPARATIVE  SURGERY  937 

(C)  Ee^xiir  ol  Damage  to  the  Orbital  Walls  and  in 
the  Bone 

We  draw  attention  to  three  procedures,  of  unequal 
value  :  (1)  metallic  plates  ;  (2)  adipose  grafts  ;  (3)  carti- 
laginous grafts. 

(1)  Metallic  Platej^. — Wc  only  know  one  author  who 
makes  use  of  metallic  plates  in  such  circumstances. 

Pierre  Duval,  in  a  communication  to  the  Societe 
de  Chirurgic  de  Paris  (June  16,  1915)  presented  a 
case  of  prothesis  of  the  left  frontal  and  superior 
orbital  margin  by  means  of  metallic  plates.  He  used 
the  aluminium  plates  which  are  manufactured  for 
military  purposes  and  which  are  four-tenths  of  a  milli- 
metre thick.  The  author  confesses  that  this  substance 
graduallj^  becomes  absorbed,  but  the  process  is  usually 
slow  and  incomplete.  "  In  a  case  of  extensive  depres- 
sion of  the  frontal  bone,"  says  Duval,  "  the  superior 
orbital  margm  was  fractured  and  depressed,  save  at 
its  extreme  two  centimetres.  I  restored  it  with  a 
plate  with  a  rounded  margin  anchored  by  its  ends  to 
the  osseous  margin."  The  extremities  of  the  prothesis 
were  let  into  the  substance  of  the  diplce  at  certain 
points  where  the  operator  had  made  small  holes  to 
receive  the  prolongations.  The  whole  was  covered 
by  the  refreshed  integument.  Duval  showed  the  case 
four  months  after  the  prothesis,  and  the  aesthetic  result 
seemed  to  be  most  satisfactory,  so  far  as  one  can  judge 
from  the  photograph  with  the  publication. 

Perhaps  we  may  be  able  to  use  in  the  same  way  the 
sheets  of  rubber  advised  by  Professor  Delbet  for 
the  restoration  of  the  abdominal  walls,  but  we  do  not 
bfelieve  that  these  procedures  can  bear  comparison 
with  the  two  following. 

(2)  Adipose  Grafts. — In  order  to  fill  up  the  orbit  and 
facilitate  the  wearing  of  a  prothesis,  it  has  long  been 
recommended  to  graft  the  spht  skin  with  cellulo -adipose 
tissue ;  and  long  before  the  interventions  necessitated 
by  the  war,  surgeons  were  cognisant  of  the  means  of 
filling-out  and  raising  cicatrices  which  were  in  vicious 
position,  sunk  in  and  adherent  to  bone,  by  introducing 


998 


FRACTURES  OF  THE  ORBIT 


beneath  them  sufficient  fat  to  transform  the  excava- 
tion into  a  rounded  projection,  rather  more  rounded 
in  fact  than  seems  at  first  necessary,  in  order  that 
after  the  inevitable  partial  absorption,  the  aspect 
of  the  exterior  should  be  as  perfect  as  possible 
(Verderame,   Annales  d'Oculistique,    1910).     In  this 


Fig.  68. 


war,  MoRESTiN  has  made  large  use  of  these  adipose 
grafts  for  the  restoration  of  vicious  cicatrices  of  the 
face,  and  the  restoring  of  bony  depressions  of  the  or- 
bital margin.  In  his  communications  to  the  Societe 
de  Chirurgie  de  Paris,  July  21  and  November  24,  1915, 
he  quotes  some  cases  of  very  extensive  facial  mutila- 
tions, in  which  a  fragment  of   fatty  tissue   has  been 


REPARATIVE  SURGERY 


999 


used  to  fill  up  the  osseous  depressions  consequent  on 
injuries  to  the  orbital  and  peri-orbital  bony  framework. 

We  have  ourselves  under  similar  circumstances  had 
recourse  to  the  same  operation,  and  can  cite  several 
cases  in  which  the  result  has  been  very  satisfactory. 

The  adipose  grafts  should  be  taken  from  the  subject 


Fig.  G9. 


himself,  from  the  lower  part  of  the  buttock  when 
it  is  desired  to  graft  adipose  tissue,  from  the  thorax 
if  it  is  wished  at  the  same  time  to  use  a  cartilaginous 
graft.  In  the  latter  event  a  single  operation  on  a 
costal  cartilage  enables  us  to  obtain  at  the  same  time 
fat  and  cartilage. 

There  is  always  a  tendency  to  resect  more  fat  than 
is  necessary  ;  it  is  well  to  ascertain  as  closely  as  possible 


1000 


FRACTURES  OF   THE  ORBIT 


the  capacity  of  the  cavity  to  be  filled,  and  a  graft  of 
dimensions  a  little  greater  should  be  taken.  If  the 
adipose  tissue  presents  connective-tissue  partitions 
rather  closely  packed  together  so  much  the  better; 
it  is  much  better  to  graft  eel lulo -adipose  tissue  than 
pure  adipose  tissue. 


Fig.  70. 


The  cellulo -adipose  graft  needs  very  careful  manage- 
ment, for  it  must  not  be  roughly  used.  After  having 
prepared  it  by  a  rapid  dissection,  it  should  be  placed 
in  a  sterilised  cloth  and  not  allowed  to  undergo  any 
unnecessary  handling.  The  bed  in  which  it  is  to 
be  placed  should  be  carefully  prepared,  so  that  the 
graft  will  not  come  in  contact  with  hard  cicatricial 
tissue,   bloodless  and  without  vitality ;    it  will  often 


REPARATIVE  SURGERY  1001 

be  necessary  to  resect  this  cicatricial  tissue  in  such 
a  manner  that  the  graft  is  surrounded  by  living  tissue, 
well  disposed  to  receive  its  guest  and  to  nourish  it. 
We  have  several  times  failed  in  our  attempt  through 
having  made  this  resection  of  cicatricial  tissue  badly 
and   incompletely.      Moreover,    it    is    necessary    that, 


Fig.  71. 

all  bleeding  should  have  been  completely  stopped  by 
hydrogen  peroxide ;  and  especially  by  pressure  with 
tampons,  or  at  need  by  catgut  ligatures,  if  torsion  of 
the  small  vessel  has  not  sufficed.  If  local  anaesthesia  be 
used,  one  must  beware  of  solutions  containing  adrena- 
lin which  yield  a  provisional  hsemostasis,  followed  by  a 
reflux  of  blood  and  a  small  post-operative  haemorrhage. 
A  graft  surrounded  by  blood,  even  if  it  be  aseptic 
blood,  is  not  under  good  conditions. 


1002 


FRACTURES  OF  THE  ORBIT 


Hence  complete  asepsis,  good  haemostasis,  the  pre- 
paration of  a  bed  free  from  cicatricial  tissue,  and  a 
graft  filling  the  cavity  well,  are  the  needful  conditions 
for  a  good  adipose  graft. 

It  is  in  this  manner  that  we  have  been  able  to  obtain 


Fig.  72. 


some  good  results,  such  as  those  shown  in  the  Figs.  70 
to  73,  referring  to  Cases  59  and  60. 

It  may  perhaps  be  remarked  that  these  operative 
results  leave  something  to  be  desired  in  the  sense 
that  there  still  persists  a  trace  of  the  injury ;  that  is 
due,  first,  to  the  circumstance  that  the  photograph, 
which  is  very  truthful,  owing  to  not  having  been 
retouched,  was  taken  before  time  had  completed  its 
work,  and  second,  to  the    fact   that  our  poilus,  in  a 


REPARATIVE  SURGERY  1003 

hurry  to  "  get  through  with  it,"  refused  the  little 
complemental  operations  by  the  aid  of  which  one  could 
easily  banish  the  vestiges  still  visible  in  Figs.  69,  71 

and  73.  , 

(3)  Cartilaginous   (^ra/«s.— Transplantations    ot    car- 
tilage in  reparative  surgery  were  advocated  by   V^on 


Fig.  73. 

Mangold  in  1903,  and  afterwards  by  Nelaton  and 
OmbredaKne,  in  the  chapter  "  Autoplastics  et  Rhino- 
plasties "  in  the  treatise  by  Hartmann  and  Berger. 
Mutilations  of  the  face  having  become  very  frequent 
since  the  war,  the  method  has  been  employed  anew 
with  success  by  Morestin.  This  surgeon  had,  since 
1913,  made  several  attempts  at  facial  restoration  by 
means  of  autoplastic  cartilaginous  transplantation  ;  his 


1004  FRACTURES  OF  THE  ORBIT 

first  papers  on  the  subject  date  from  May  7,  1913  and 
November  11,  1914,  before  the  Societe  de  Chirurgie  de 
Paris.  At  the  Congress  of  the  International  Society 
of  Surgery  of  New  York  (April,  1914)  Morestin  was 
in  charge  of  the  report  on  grafts  and  transplantations 
in  reparatory  surgery.  Since  1915,  by  the  aid  of 
numerous  communications,  he  has  perfected  our  know- 
ledge of  the  techniqiie  of  the  operation,  and  has  shown 
the  brilliant  results  obtained,  not  only  in  building  up 
the  nose  or  the  lower  jaw,  but  also  in  the  restoration 
of  the  orbital  walls  destroyed  by  injuries  of  war. 

We  shall  review  some  of  the  publications  of  this 
master  of  autoplastic  surgery. 

MoRESTiN  reports  the  case  of  a  soldier  ^  who  presented 
a  curvilinear  cicatrix  at  the  lower  part  of  the  forehead 
above  the  left  eyebrow ;  the  superciliary  arch,  the 
orbital  margin  and  the  lower  portion  of  the  frontal  bone 
between  the  orbit  and  the  frontal  prominence  were 
wanting.  A  deep  depression  corresponded  to  this 
loss  of  bone  substance  over  which  cerebral  pulsation 
could  be  seen  and  felt.  In  two  preliminary  operations 
MoRESTiN  removed  the  projectile  which  was  found  at 
the  inferior  part  of  the  frontal  sinus,  then  extirpated 
a  fistulous  track  at  the  internal  part  of  the  frontal 
cicatrix. 

Two  months  after  recovery  from  this  operation,  the 
cicatrix  was  in  turn  removed,  ligaments  were  loosened 
to  prepare  a  bed  for  the  graft,  which  was  borrowed 
from  another  subject ;  the  cartilage  was  shaped  to 
the  form  of  the  superior  orbital  arch  and  the  wound 
hermetically  closed.  The  result  was  most  satisfactory, 
as  the  photographs  testify. 

In  a  second  article ,2  Morestin  publishes  two  similar 
cases.     A  man,  wounded  by  a  bullet,  presented  at  the 

1  MoRESTiN.  On  the  repair  of  loss  of  substance  of  the  cranium, 
and  particularly  of  the  forehead,  by  means  of  transplantation  of 
cartilage. — Societi  de  Chirurgie  de  Pa.'is,  February  9,  1916. 

2  On  the  reconstitution  of  the  malar  bone  and  the  orbital  margin 
by  means  of  transplantation  of  cartilage. — Societe  de  Chirurgie  de 
Paris,  March  1,  1916. 


REPARATIVE  SURGERY  1005 

level  of  the  right  cheekbone  a  very  deep  scar  in  the 
form  of  a  star  with  four  rays,  closely  adherent  to 
the  subjacent  tissue.  The  depression  corresponded  to 
the  prominence  of  the  malar  bone  and  the  orbital 
margin.  The  sixth  and  seventh  costal  cartilages  were 
removed,  xmited  one  to  the  other ;  the  thoracic  wound 
was  closed  in  layers  by  sutures.  The  orbito -malar 
cicatrix  having  been  extirpated,  the  surrounding 
integuments  were  freely  undermined.  After  having 
examined  the  gap  in  the  bone,  a  large  piece,  almost 
identical  in  shape,  was  carved  out  of  the  cartilaginous 
block,  reconstituting  the  malar  bone  and  the  orbital 
margin.  As  it  lacked  stability,  Morestin  fixed  it  by 
means  of  another  fragment,  the  whole  being  sutured  to 
the  temporal  muscle  and  covered  by  the  superficial 
layers.  The  wound  healed  in  a  week  and  the  result 
was  aesthetically  perfect.  The  second  case  was  a 
soldier,  bearing  a  very  apparent  deformity,  resulting 
from  the  destruction  of  the  external  portion  of  the 
right  inferior  orbital  margin  and  the  anterior  portion 
of  the  right  malar  bone.  The  bony  portion  was  filled 
up  by  means  of  split  cartilaginous  fragments  derived 
from  a'nother  subject,  placed  with  the  epidermic  sur- 
face turned  towards  the  deep  portion  of  the  cavity. 
MoRESTiN  completed  their  modelling  in  the  wound,  to 
^ensure  that  their  adaptation  should  be  as  perfect  as 
possible.  Rapid  healing  in  a  few  days.  Morestin 
finishes  his  paper  by  saying  :  "  These  two  cases  show 
what  one  may  expect  from  cartilaginous  transplanta- 
tion in  this  kind  of  deformity.  The  method  which 
I  have  recommended  provides  a  very  simple  solution 
to  a  problem  of  reparatory  surgery  which  has  hitherto 
remained  unsolved." 

On  May  31,   1916,^  two  new  cases  were  presented 

1  Morestin.  (1)  Reconstitution  of  the  malar  bone  and  the 
orbital  margin  by  means  of  cartilaginous  transplantation.  (2)  Loss 
of  left  eye;  comminuted  fracture  of  the  superior  maxilla,  de- 
struction of  the  orbital  margin,  operation  for  repair ;  cartilaginous 
grafts.  (3)  Reconstitution  of  the  malar  bone  and  the  external 
half  of  the  orbital  margin  by  cartilaginous  transplantation. — Societe 
de  Chirvrgie  de  Paris,  May,  1916. 


1006  FRACTURES  OF  THE  ORBIT 

by  this  author,  with  complete  operative  and  aesthetic 
success.  In  these  cases  'there  was  very  extensive 
damage  to  the  orbital  walls  with  and  without  preser- 
vation of  the  eyeball.  At  the  same  meeting,  Mores- 
tin  showed  a  soldier  for  whom,  on  August  10,  1915, 
he  had  reconstituted  the  malar  bone  and  the  external 
half  of  the  orbital  margin  by  cartilaginous  transplanta- 
tion (about  ten  months  before),  a  case  which  suggested 
to  him  the  following  reflections  :  "It  appears  to  me 
that  it  is  interesting  to  demonstrate,  by  this  example, 
how  one  can,  on  the  same  subject,  perform  successive 
graftings  of  cartilage  borrowed  from  himself  or  from 
others ;  it  is  equally  useful  as  showing  the  stability  of 
the  transplanted  grafts.  The  cartilaginous  mass  has 
undergone  no  reduction  in  size  during  this  lapse  of  time. 
I  never  lose  an  opportunity  of  insisting  upon  the 
stability  of  the  results  of  cartilaginous  grafts.  That 
is  an  essential  point,  one  of  the  fundamental  reasons, 
which  allow  us  to  advocate  this  method  in  reparative 
surgery." 

Speaking  of  another  case,  Morestin  fully  demon- 
strates his  manner  of  procedure,  and  we  cannot  do 
better  than  summarise  it 

Amongst  injuries  of  the  face,^  there  is  a  type  which 
one  meets  frequently.  In  it  the  eyelids  are  more  or 
less  torn  through,  the  eyeball  often  injured,  the  malar 
bone  and  the  external  wall  of  the  orbit  carried  away 
or  destroyed  over  a  large  extent.  The  interrupted 
orbital  margin  is  wanting  in  its  infero -external  portion, 
the  integuments  of  the  malar,  temporal  and  mandi- 
bular regions  participate  in  the  deformity.  There  is 
an  enormous  bony  depression,  associated  with  shocking 
facial  asymmetry  and  vicious  position  of  the  eyelids 
by  reason  of  irregular  and  very  extensive  cicatrices. 

In  these  cases,  "  Reparation  has  to  be  preceded  by 
the'^  excision  and  the  gradual  reduction  of  the  cica- 
trices."    It   is    best    to    proceed    by   two    successive 

1  MoRESTiN.  Reconstitution  of  the  malar  bone  and  of  the  orbital 
margin  by  cartilaginous  transplantation. — Societi  de  Chirurgie  de 
PariSy  August  9,  1916. 


REPARATIVE  SURGERY  1007 

operations.  In  the  first  place  an  autoplasty  is  made, 
having  as  its  object  the  restoration  of  the  destroyed 
integuments ;  after  having  liberated  and  brought  the 
eyelids  into  good  position  and  performed  blepharor- 
raphy,  a  flap  is  fashioned  from  the  temple  and  the 
adjoining  portion  of  the  forehead,  a  flap  whose 
pedicle  must  often  be  taken  from  behind  because  of 
the  cicatrices  which  occupy  the  anterior  part  of  the 
region.     This  flap  is  put  in  position  and  sutured. 

After  five  or  six  weeks  the  restoration  of  the  bony 
framework  can  be  proceeded  with.  One  of  the  cica- 
trices is  reopened,  the  fiap  is  detached  with  the  neigh- 
bouring integuments,  the  conjunctival  sac  is  put  on 
one  side,  with  the  intra-orbital  soft  parts,  avoiding, 
at  all  costs,  the  opening  of  the  conjunctiva  or  the 
maxillary  sinus.  The  boundaries  of  the  loss  of  osseous 
substance  are  examined,  the  breach  is  prepared,  the 
grafts,  taken  from  the  patient  himself  (the  sixth  and 
seventh  costal  cartilages),  are  trimmed  to  the  size  and 
shape  required  and  installed  in  place.  Finally  the 
wound  is  hermetically  sealed.  It  only  remains,  a 
few  days  later,  to  separate  the  eyelids  and  insert  an 
artificial  eye,  if  the  globe  has  been  destroyed  by  the 
injury  or  sacrificed  by  necessity. 

With  regard  to  this,  it  should  be  noted,  adds 
MoRESTiN,  that  in  cases  in  which  the  eye  is  lost,  it  may 
be  advisable  during  the  course  of  the  operation  of 
grafting,  to  slip  some  fragments  of  cartilage  into  the 
interior  of  the  orbit,  so  as  to  push  forward  the  con- 
junctival sac  and  thus  permit  the  wearing  of  an  artificial 
eye  under  the  best  possible  conditions. 

After  the  account  of  the  procedure  employed  and 
the  results  obtained  by  Moresti:n",  whose  methods 
seem  to  us  particularly  worthy  of  approval,  we  shall 
give  an  account  of  those  we  have  used  in  our  clinic 
during  the  same  period  as  our  colleague  and  often 
inspired  by  his  counsel. 

Two  different  conditions  may  present  themselves  : 
either  the  fractured  orbit  communicates  with  the  neigh- 
bouring cavities,   the  maxillary  sinus  and  the  nasal 


1008  FRACTURES  OF  THE  ORBIT 

fossa,  or  the  loss  of  substance  affects  only  the  orbital 
margin  over  a  greater  or  less  extent,  without  the 
adjoining  cavities   being  implicated. 

{a)  When  the  neighbouring  cavities  are  in  communi- 
cation with  the  orbit,  it  is  needful  in  the  first  place  to 
shut  off  this  communication ;  should  the  maxillary 
sinus  suppurate,  it  must  be  curetted,  freely  opened 
by  the  side  of  the  nose,  or  if  necessary  a  radical  cure 
performed  by  the  classic  method.  No  surgical  inter- 
ference with  the  wall  of  the  orbit  is  permissible  until 
a  complete  result  has  been  obtained  on  the  side  of  the 
antrum.  Moreover,  it  is  unnecessary  to  hurry,  de- 
liberate operations  are  the  best. 

In  a  considerable  number  of  cases  the  projectile, 
which  has  smashed  up  at  the  same  time  the  floor  of  the 
orbit  and  the  maxillary  antrum,  has  spared  the  con- 
junctival mucous  membrane ;  this  torn  mucous  mem- 
brane, separated  from  its  normal  relations,  is  a  great 
help  in  isolating  the  orbit  from  the  neighbouring 
cavities  ;  by  dissecting  it  up  in  an  appropriate  manner, 
it  can  be  drawn  towards  the  opening,  and  sutured  there, 
its  deep  surface  against  the  neighbouring  cavity.  In 
this  manner  all  communication  with  the  nasal  fossae 
can  be  cut  off.  When  the  region  of  the  lacrymal  sac 
has  been  extensively  destroyed,  we  have  been  able  to 
obtain  this  result  after  several  interventions ;  we 
could  cite  here  several  cases  of  this  kind  in  which 
there  has  been  great  damage,  opening  up  communi- 
cations between  the  orbit,  the  nasal  fossae,  and  the 
antrum. 

When  the  frontal  sinus  has  been  widely  opened  in 
front  and  on  the  orbital  side,  it  is  necessary  to  wait 
until  suppuration  has  disappeared  and  a  cicatrix  has 
taken  the  place  of  the  fleshy  granulations  V  later,  by 
an  adipose  or  cartilaginous  graft  it  will  be  possible, 
even  easy,  to  fill  up  the  cavity. 

Hence,  so  long  as  the  cavities  adjoining  the  orbit 
communicate  with  it  and  suppurate,  we  must  attend 
to  them,  to  cure  them  in  the  first  place  so  as  to  have  to 
do  with  the  orbit  alone.     Then  we  shall  be  in  the  con- 


REPARATIVE  SURGERY  1009 

ditions  realised  at  the  outset  by  fractures  which  involve 
the  orbital  margins  or  the  external  surface,  without 
communication  with  the  neighbouring  cavities. 

(b)  When  the  orbit  alone  is  fractured,  it  is  usually 
the  region  of  the  cheek-bone  which  bears  the  brunt 
of  the  traumatism.  The  malar  bone  is  crushed  and 
destroyed ;  in  its  place  is  a  deep  depression,  the  lower 
eyelid  is  torn  to  rags,  and  the  eye  usually  carried  away 
by  the  projectile  or  removed  by  the  first  surgeon  who 
attends  to  the  casualty.  When  the  eye  is  preferved, 
it  is  often  in  a  condition  of  enophthalmos  because  the 
floor  of  the  orbit  is  sunk  in  towards  the  maxillary  sinus, 
or  because  there  is  absorption  of  the  cellulo -adipose, 
cushion  which  supports  the  globe.  The  upper  margin 
of  the  orbit  is  sometimes  alone  injured,  and  there  exists 
in  its  place  a  large  very  misightly  hollow. 

All  these  disfigurements  can  easily  be  repaired  by 
cartilaginous  grafts,  and  we  cannot  too  strongly 
recommend  to  our  colleagues  the  method  initiated  by 
Von  Mangold,  and  admirably  brought  to  perfection 

by  MORESTIN. 

We  have  acquired  some  experience  in  this  method 
of  surgical  intervention,  and  we  will  place  before 
our  readers  the  results  of  our  work,  as  well  as  the 
inevitable  difficulties  which  we  have  encountered  :  the 
more  because  we  performed  the  operations  at  the  same 
period  as  Morestin,  or  a  little  later,  before  becoming 
well  acquainted  with  our, colleague's  technique.  We 
have  therefore  had  to  make,  so  far  as  concerns  this 
subject,  a  personal  apprenticeship. 

Cartilaginous  grafts  are  in  truth  a  conquest  of  modern 
surgery ;  they  ai?e  more,  useful,  more  readily  affected, 
and  more  reparative  than  adipose  grafts.  Everything 
has  been  said  by  Morestin  concerning  the  operative 
procedure,  and  we  have  intentionally  quoted  him  fully 
above.  We  shall  only  add  some  details  which  will  put 
our  readers  on  their  guard  against  certain  mistakes 
which  we  have  ourselves  committed,  and  which  will 
enable  them  to  comprehend  what  we  have  to  expect 
in  this  kind  of  operative  interference. 


1010  FRACTURES  OF  THE  ORBIT 

In  the  first  place  we  must  emphasise  that  it  is 
necessary  to  be  resigned  to  successive  operations. 
We  have  made  the  mistake  of  wishing  to  do  too  much 
at  once.  Some  of  our  patients  were  eager  to  have 
finished  with  the  business,  and  we  allowed  ourselves 
to  be  influenced  by  it  in  our  surgical  conduct.     We 


Fig.  74. 

were  not  afraid  to  do,  the  same  day,  a  large  blepharo- 
plasty  with  pedicle,  an  adipose  graft  and  a  cartilaginous 
graft ;  we  have  succeeded  sometimes  from  all  three 
points  of  view,  and  we  have  at  this  moment  under 
our  care  a  fortunate  example ;  but  we  have  failed 
several  times,  and  we  do  not  recommend  this  course 
of  action.  It  is  an  error,  in  fact,  to  graft  a  piece  of 
cartilage  to  take  the  place  of  the  orbital  margm,  to 


REPARATIVE  SURGERY  1011 

cover  it  with  adipose  tissue  and  to  suture  over  the 
whole  a  raw  flap.  The  flap  destined  to  become  an 
eyeUd  needs  to  rest  upon  a  solid  foundation,  upon  a 
tissue  capable  of  giving  it  nourishment,  not  upon  a  graft 
which  has  need  of  receiving  nourishment  itself.  It  will 
be  necessary,  when  dealing  with  such  a  case,  to  make 


Fig.  75. 

the  patient  understand  that  two  operations  are  neces- 
sary. We  commence  at  first  with  a  blepharoplasty, 
and,  six  weeks  later,  we  introduce  under  the  skin  the 
necessary  cartilage  and  cellulo -adipose  tissue.  Figs. 
74  and  75  are  very  instructive  from  this  point  of  view ; 
we  attempted  to  do  everything  at  once,  with  the 
result  that  the  adipose  graft  has  been  eliminated. 
The  adipose   graft  is  ehminated,   but  the   cartilage 


1012 


FRACTURES  OF  THE  ORBIT 


has  held  perfectly,  and  it  is  a  detail  to  which  I  would 
particularly  call  attention ;  cartilage  will  easily  live 
wherever  it  is  put,  it  is  content  with  aseptic  surround- 
ings and  some  interstitial  liquids  to  penetrate  it.  It 
lives  as  a  parasite,  frugally,  but  it  does  live  and  remains 
as  cartilage.     It  is  quite  remarkable  to  see  it  persist, 


Fig.  76. 


and  maintain  its  position  and  its  good  appearance  at 
the  bottom  of  a  cavity  which  has  not  been  able  to 
retain  the  fat  with  which  we  had  filled  it. 

This  demonstrates  what  one  may  expect  from  a 
graft  of  cartilage  made  aseptically,  and  introduced 
into  its  position  by  means  of  a  button-hole  which 
allows  it  to  insinuate  itself  into  the  subcutaneous 
interstitial    tissue    to    the    desired    depth.      Cartilage 


REPARATIVE  SURGERY 


1013 


thus  grafted  always  succeeds  ;  Morestin  has  shown  at 
the  Societe  de  Chirurgie  cases  which  are  relatively  old ; 
we  can  cite  very  instructive  cases  of  a  similar  nature. 

The  illustrations  above  show  some  of  our  results. 
They  would  have  been  more  complete  if  it  had  been 
possible    for    us    to    perform    some    small    retouching 


Fig.  77. 


operations  on  the  patients.  Such  as  they  are,  how- 
ever, Figs.  74  and  75,  76  and  77  show  that  the  orbital 
arches  can  be  restored.  In  the  first  case,  the  adipose 
tissue,  grafted  at  the  same  time  as  the  cartilage,  was 
eliminated  ;  in  the  second,  the  orbital  arch  has  been 
completely  re-established,  the  eye  is  not  wide  open 
because  the  subject  was  enophthalmic  owing  to  depres- 
sion of  the  orbital  floor. 


1014  FRACTURES  OF  THE  ORBIT 

Moreover,  it  is  quite  easy  to  obtain  the  cartilaginous 
graft.  Its  dissection  causes  no  inconvenience,  im- 
mediate or  remote  ;  when  aseptic  the  wound  does  not 
suppurate,  and  it  is  quite  sufficient,  in  order  to  ensure 
that  the  thoraco -abdominal  wall  should  also  remain 
aseptic,  that  while  the  operator  is  finishing  the  orbital 
operation  the  assistant  in  charge  of  the  thoracic  wound 
should  close  the  incision  neatly,  with  catgut,  in  layers, 
with  a  muscular,  an  aponeurotic,  and  a  cutaneous  series 
of  sutures. 

We  take  up  a  fragment  of  cartilage  a  little  larger 
than  is  required,  and  shape  it  at  will,  cutting  it  to  give 
it  the  requisite  form.  The  little  fragments  serve  as 
packing  for  the  principal  piece  ;  thus  one  builds  up 
in  the  site  of  the  orbital  margin  or  the  malar  bone 
an  edifice,  like  a  wall,  which  will  replace  that  which 
the  projectile  has  destroyed. 

Such  are  the  principal  reflections  inspired  by  our 
experience  of  cartilaginous  grafts,  we  are  doing  this 
kind  of  operation,  more  and  more,  and  with  increasing 
confidence ;  and,  if  we  do  not  cite  a  large  number  of 
cases,  it  is  because  many  of  them  are  too  recent  to  take 
their  place  in  this  work. 

When,  by  reason  of  their  long  standing  they  merit 
to  be  published,  we  shall  make  them  the  subject  of  a 
special  article. 


CONCLUSIONS 

In  conclusion,  we  wish  to  bring  forward  the  original 
ideas  developed  in  this  work  : 

(1)  We  wish  to  call  attention  in  the  first  place  to 
this  fact,  that  fractures  of  the  cranium  by  projectiles 
of  war,  implicating  the  cranial  vault,  at  a  certain 
distance  from  the  orbit,  even  when  they  are  accom- 
panied by  large  losses  of  substance  and  in  consequence 
by  well-marked  concussion,  do  not  give  rise  to  either 
irradiation  or  fracture  by  contre-coup  of  the  vault  of 
the  orbit.  Contrary  to  what  is  taught  in  the  classic 
literature,  the  sphenoidal  fissure,  the  optic  foramen, 
and  the  structures  which  pass  through  them  remain 
unharmed  after  such  traumatism. 

In  military  surgery,  fractures  of  the  orbital  vault 
are  direct  fractures. 

(2)  The  eye  is  often  involved  in  fractures  of  the 
orbit,  even  when  neither  the  projectile  nor  bone  frag- 
ments have  directly  touched  it ;  there  are  produced, 
at  the  macula  or  around  it,  concussion  lesions,  well- 
marked  and  very  serious  ;  they  can  be  seen  by  means  of 
the  ophthalmoscope  in  the  form  of  haemorrhages  or 
lacerations,  sometimes  only  choroidal,  often  choroido- 
retinal. 

In  addition  to  lesions  visible  to  the  ophthalmoscope 
we  may  note  the  disorders  which  cannot  be  seen. 
The  central  visual  acuity  of  ,a  subject,  whose  eje 
appears  absolutely  intact,  may  be  very  low ;  these 
disorders  may,  further,  up  to  a  certain  limit,  be  re- 
paired, but  their  importance  should  be  considered 
as  of  the  first  order  by  clinicians  in  the  establishment 
of  their  diagnosis  and  in  military  medico -legal  certifi- 
cates.    The  affections  described   under  the   name   of 

1015 


1016  FRACTURES  OF  THE  ORBIT 

'■  retinal  concussion  "  are  the  first  degree,  the  degree 
invisible  to  the  ophthalmoscope,  of  these  lesions  due 
to  concussion  from  a  distance. 

(3)  Besides  these  concussion  lesions  we  have,  in 
this  work,  brought  prominently  forward  the  lesions 
of  contact  produced  by  a  projectile  which  has  grazed 
or  slightly  contused  the  eye  while  passing  alongside 
it,  or  by  an  osseous  fragment  more  or  less  violently 
projected  towards  the  eyeball. 

Concussion  lesions  and  contact  lesions  often  exist 
together ;  a  minute  ophthalmoscopic  examination  allows 
these  varieties  of  lesions  to  be  allotted  their  respective 
shares  in  the  anatomical  derangements  undergone  by 
the  deep  membranes. 

(4)  Between  the  production  of  these  various  dis- 
orders and  the  manner  in  which  the  projectile  has 
injured  the  orbit,  there  exist  relations  so  constant 
that  we  have  been  able  to  formulate  the  clinical  data 
under  the  form  of  -laws,  the  accuracy  of  which  we 
are  verifjdng  every  day,  and  to  which  we  think  we 
should  draw  the  attention  of  our  colleagues  in  a  special 
manner  (p,813et  seqq.). 

(5)  When  the  retina  and  choroid  are  much  torn,  there 
is  produced,  as  the  result  of  more  or  less  abundant  intra- 
ocular haemorrhage,  not  the  classic  proliferating  retinitis, 
but  a  choroido -retinitis  presenting  peculiar  characters, 
which  we  have  attempted  to  bring  into  prominent 
relief,  and  which  cause  this  affection  to  be  a  morbid 
type,  not  hitherto  described. 

The  cases,  frequent  in  military  surgery  and  rare 
in  civil  ophthalmology,  of  total  avulsion  of  the  optic 
nerve,  produce  this  proliferating  choroido -retinitis  in 
maximum  degree. 

(6)  One  detail  which  has  impressed  us,  amongst  our 
patients,  is  the  absence  of  partial  scleral  ruptures 
produced  according  to  the  theorj^  of  the  equator  of 
depression.  The  projectiles  which  strike  the  eye 
tangentially  cause  lesions  of  contact;  if  they  contuse 
the  eye  with  sufficient  directness  to  break  its  fibrous 
framework,    they   smash   it    completely   and   destroy 


CONCLUSIONS  1017 

it ;  there  is  no  place  in  military  ophthalmology  for 
ruptures  of  the  sclerotic  in  the  intercalary  region 
and  subconjunctival  luxations  of  the  lens,  etc.  .  .  . 
Projectiles  which  strike  the  eye  directly  penetrate  its 
interior  if  they  are  small;  if  they  are  large  they 
destroy  it,  the  organ  is  entirely  disorganised. 

After  thirty  months  of  practice  and  seeing  more  than 
six  hundred  fractures  of  the  orbit,  we  have  not  seen 
a  single  case  which  departs  from  this  rule ;  doubtless 
exceptions  may  be  met  with,  but. the  clinical  verity, 
which  we  lay  down  here,  remains  on  a  basi^  none  the 
less  solid. 

(7)  We  have  further,  by  means  of  our  cases,  been 
able  to  make  a  special  study  of  hsematomata  of  the 
sheaths  of  the  optic  nerve,  and  we  are  confident  that 
the  haemorrhage  does  not  spread  along  them  into  the 
ocular  cavity,  as  the  best  authorities  have  taught; 
but  that  the  haematic  pigment,  after  a  rather  long 
period  of  time,  diffuses  as  far  as  the  disc,  and  pro- 
duces a  pigmented  crescent  or  ring,  the  direct  conse- 
quence of  the  haemorrhage.  There  is  not  propagation 
to  the  papilla  of  a  recent  haemorrhage  into  the  sheaths 
of  the  nerve ;  but  there  is,  secondarily,  somewhat 
slowly,  migration  of  the  haematic  pigment. 

(8)  So  far  as  therapeutics  are  concerned,  this  work 
contains  information  upon  reparative  surgery  of  the 
orbit  by  means  of  adipose  and  cartilaginous  grafts, 
to  which  we  consider  it  our  duty  to  call  the  attention 
of  ophthalmologists,  whose  *  place  it  is  to  maintain 
the  surgery  of  the  orbit  abreast  of  progress  of  every 
kind. 


LIST  OF  CASE -REPORTS 


1.  Fracture    of   right    orbit    by 

rifle  bullet,  814-15 

2.  Fracture  of  superior  wall  of 

left  orbit  and  frontal  sinus 
by  shell  fragment,  816 

3.  Fracture  of  right  superior  or- 

bital margin  with  atrophy 
of  optic  nerve,  817 

4.  Fracture  of   both   orbits   by 

bullets.  817-18 

5.  Fracture  of  both  orbits,  with 

haemorrhage  into  vitreous 
body,  R.  E.,  and  macular 
choroiditis,  L.  E.,  818-19 

6.  Bullet    traversing    face,     bi- 

lateral macular  haemor- 
rhage, 820-1 

7.  Fracture  of  right  orbit,  lacer- 

ation of  choroid,  optic 
atrophy,  R.  E.,  821-2 

8.  Wound  of  facial  bones,  macu- 

lar and  peripheral  choroi- 
do-retinitis.  R.  E.,  822-4 

9.  Fracture  of  external  wall  of 

right  orbit;  macular  cho- 
roido-retinitis;  avulsion  of 
optic  nerve,  824 

10.  Fracture  of  external  wall  of 

left  orbit,  choroido-retini- 
tis.  L.  E.,  825 

11.  Fracture  of  left  orbit,  section 

of  optic  nerve,  neuro-para- 
lytic  keratitis,  825-7 

12.  Fracture  of  both  orbits,  reti- 

nal haemorrhage ,  R.  E., 
detachment  of  choiroid, 
L.  E.,  detachment  of  reti- 
na, R.  E.,  827-9 

13.  Fractures     of     both     orbits, 

retinal  haemorrhage,  R.  E., 
retinitis  proliferans,  L.  E., 
829-30 

14.  Fracture  of  right  orbit,  rup- 

ture choroid,  R.  E.,  830-1 

15.  Fracture    of    floors    of    both 

orbits;  double  retinal  de- 
tachment; macular  lesion 
by  concussion,  832-3 

16.  Fracture  of  left  orbit,  detach- 

ment of  retina,  L.  E.,  833-4 

17.  Bullet  wound  of  face;    frac- 

ture of  left  inferior  orbital 
margin;  detachment  of 
retina,  L.  E.,  834-5 

18.  Fracture  of  left  orbit,   rup- 

ture of  choroid,  836-7 


19.  Fracture  of  right  orbit;    for- 

eign body;  macular  cho- 
roid o-retinitis,  837-9 

20.  Fracture  of  superior-external 

margin  of  right  orbit;  for- 
eign body;  choroid  o-retini- 
tis, R.  E.,  839-41 

21.  Fracture  of  left  orbit;   foreign 

body;  optic  atrophy  and 
choroido-retinitis,  841-2 

22.  Fracture  of  left  orbit;   optic 

atrophy,  843-4 

23.  Fracture  of  right  orbit;  for- 

eign body ;  extraction 
by  Kronlein's  method , 
844-6 

24.  Fracture  of  external  wall  of 

left  orbit;  foreign  body; 
retinal  detachment,  846-8 

25.  Fracture  of  left  orbit;    for- 

eign body;  macular  cho- 
roiditis, 848-9 

26.  Fracture  of  left  orbit;    total 

ophthalmoplegia;  optic 
atrophy,  L.  E.,  857-9 

27.  Fracture    of    right    superior 

orbital  margin ;  hsemor- 
rhage  into  sheaths  of  optic 
nerve,  868-9 

28.  Fracture  of  left  orbit,    right 

macular  chof-oido-retihitis, 
869-70 

29.  Fall  on  head  from  shell  ex- 

plosion; indirect  lesion  of 
optic  nerve ;  haematoma  of 
sheath,  870-1 

30.  Wound    of    right    temporal 

fossa,  detachment  of  re- 
tina, R.  E.,  899-900 

31.  Perforating  wound   of  right 

temporal  fossa,  rupture  of 
choroid,  R.  E.,  900 

32.  Contusion     of    left     orbital 

margin,  rupture  of  choroid, 
L.  E.,  900-1 

33.  Traumatism  of  malar  region; 

optic  neuritis;  rupture  of 
choroid,  R.  E.,  901 

34.  Perforating  wound  of  right 

orbit,  rupture  of  choroid, 
R.  E.,  902 

35.  Bullet  wound  traversing  ma- 

lar bones  and  nasal  fossa; 
choroido-retinitis,  L.  E.- 
902-3 


1019 


1020 


LIST  OF  CASE-REPORTS 


36."  Traumatism  of  the  malar 
region ;  rupture  of  choroid, 
retinitis  proliferans,  L.  E., 
903 

37.  Traumatism  of  bones  of  fare; 

rupture  of  choroid,  L.  E., 
903 

38.  Progressive  myopia;    macu- 

lar choroido-retinitis,  R. 
E.,  904-5 

39.  Section   of  sympathetic;  en- 

ophthalmos;  Claude  Ber- 
nard's syndrome;  recovery, 
921-2 

40.  Fracture     of     right     orbit; 

enophthalmos  consecutive 
upon  trophic  troubles,  925 

41.  Contusion  of  left  orbital  re- 

gion, probably  fracture; 
traumatic  enophthalmos, 
L.  E.;  trophic  troubles, 
925-7 

42.  Paralysis   of  external   rectus 

and  consecutive  trophic 
troubles,  927-8 

43.  Fracture  of  left  orbit ;  foreign 

body  in  right  orbit;  atro- 
phic and  pigmentary  cho- 
roido-retinitis, 929-31 

44.  Fracture  of  left  orbit;    trau- 

matic enophthalmos;  total 
detachment  of  retina,  931- 
33 

45.  Post-traumatic      enophthal- 

mos; depression  of  exter- 
nal orbital  wall  and  inferior 
orbital  margin,  933^ 

46.  Fracture  of  left  orbit;  rup- 

ture of  eyeball;  arterio- 
venous aneurism  of  left  in- 
ternal carotid,  938-9 

47.  Fracture  of  left  orbit:    rup- 

ture of  eyeball,  940 

48.  Fracture  of  right  orbit;  rup- 

ture of  right  eyeball;  trau- 
matic choroido  -  retinitis 
and  optic  atrophy,  L.  E., 
940-1 

49.  Fracture  of  right  orbit;   rup- 

ture of  eyeball,  941-2 

50.  Wound  of  left  temporo-orbi- 

tal  region;  fracture  of  ex- 
ternal wall  of  orbit;  rup- 
ture of  eyeball;  foreign 
body  in  orbit,  943-4 

51.  Fracture  of  right  orbit;  rup- 

turfe  of  eyeball;  foreign 
body, 944-5 


53. 
54. 


55 


56. 


52.  Foreign  body  irritating  optic 
neTve;  sympathetic  oph- 
thalmia, 945-6 

Fracture  of  floor  of  left  orbit; 
crushing  of  eyeball, 949-5 1 . 

Fracture  of  left  orbit  and  left 
maxillary  sinus;  rupture 
of  left  eyeball,  951 

Fracture  of  right  orbit  and 
frontal  sinus;  destruction 
of  eyelids  and  right  eye- 
ball; voluminous  foreign 
body  in  left  maxillary  an- 
trum, 951-2 

Fracture  of  internal  wall  of 
left  orbit;  destruction  of 
nasal  wall  and  antrum; 
rupture  of  eyeball,  b\iry- 
ing  of  eye  in  antrum,  953 
57.  Fracture  of  floor  of  right  or- 
bit; cicatricial  ectropion; 
choroid o-retinitis ;  foreign 
body  in  antrum,  954 

Fracture  of  supero-internal 
orbital  wall;  opening  of 
left  frontal  sinus,  956 

Fracture  of  facial  bones, 
frontal  sinus  and  ethmoid; 
adipose  graft,  957-8 

Fracture  of  left  fronto-orbital 
region  involving  frontal 
sinus ;  haemorrhage  into 
vitreous  body ;  adipose 
graft,  958 

Fracture  of  left  orbit ;  retro- 
bulbar neuritis,  L.  E., 
960-2 

Fracture  of  left  orbital  vault; 
perforation  of  globe;  total 
detachment  of  retina,  962- 
63 

Fracture  of  apex  of  left  orbit; 
bilateral  papillary  stasis; 
"mal  comitial,"  963-4 
64.  Fracture  of  left  orbital  region 
involving  vault;  loss  of 
cerebral  substance;  con- 
tusion of  globe;  haemor- 
rhage into  the  vitreous 
body,  964-5 

Fracture  of  right  orbit;  rup- 
ture of  left  ej-eball;  cere- 
bral abscess;  recovery, 
965-6 

Smash  of  orbital  vault;  rup- 
ture of  eyeball ;  intra-orbi- 
tal  meningo-encephalocele; 
96(j-7 


58. 


59. 


60. 


61. 


62. 


6: 


65. 


66. 


INDEX 


Abnormal  mobility,  determination 
of,  in  fractures  of  mandi- 
ble, 633  et  seq. 
Abscess,  sub-dural,   under  frontal 

lobe,  965-966,  968. 
Acetozone,  93-94. 
Active  movements,  in  after  treat- 
ment, 157  et  seq. 
Acuity,  visual,  1014-1015. 
Adipose  grafts,  932,  940,  958,  997- 

1003. 
.Etiology  of  fractures  of  the  orbit, 

802-806. 
Affections     of     visual     apparatus, 
laws     governing,    in     in- 
juries of  orbit,  813  et  seq. 
Air  passages,  clearing  of,   in  dys- 
pnoea, 630. 
Albucasis  on  orbital  lesions,  778. 
Alquier's  appliance,  420,  539. 
Ambulance  cases  seen,  figures,  5. 
Amnesia,  963. 
Amputation,  10. 

Amputation     and     esquillectomy, 
choice  between,  340. 
at  knee.  214-215. 
indications  for,  13,  15.  17,  229. 
of  foot,  244,  260. 
of  thigh,  consequent  on  wounds 

of  knee,  204. 
total  of  hand,  173. 
Anaerobes,  living,  introduction  of, 
(Donaldson's    method), 
100. 
Anatomical  features: 

of  fracture  of  neck  of  humerus, 
385. 
sub-deltoid  fracture,  400. 
shaft  of  humerus,  406. 
supra-con dylar  fracture,  433. 
of  fractures  of  forearrrt,   above 
elbow  joint,  441. 
shaft,  446. 
of  fractures  just  above  wrist,  460. 


Anatomical  features: 

of  fracture  of  shaft  of  raditis,  465. 
of  fracture  of  lower  radial  epi- 
physis, 476. 
of     fractures     of     femur,     sub- 
trocnanteric,  494. 
shaft,  507. 

supra-condylar,  547. 
of  fractures  of  leg,  shafts,  554. 
of  supra-malleolar  fractures,  569. 
Anchorage    of    fragments    of    jaw, 

debatable  question,  713. 
Anesthesia,  343. 

cutaneous,      with      fracture      of 

mandible,  638-639. 
in  fractures  of  jaw,  740-741. 
Anesthetic,  choice  of,  in  fractures 

of  mandiblet,  741. 
Aneurism,   arterio-venpus,  accom- 
panying    orbital     lesion, 
939,  942. 
cause  of,  874. 
Angle's  apparatus  for  paramedian 

fracture  of  jaw,  683. 
Angle's  arch,  663. 

adjustment  of,  665. 
Ankle,   wounds   and.  fractures   of, 

234  et  seq. 
Ankle  wounds,  typesiof,  237. 
Ankylosis,  and  sinus^,  169. 
avoidance  of,  32. 
of  jaw,  permanent,  649. 
production  of,  31  > 
vicious,  254. 
"Anse  calcaneenne,     243. 
Anterior    fractures    of    mandible, 

599,  676. 
Anterior  Tarsus,  resection  of,  258. 
Apparatus^,  fitting  oi    in   fracture 
of  thigh,  532 
for  expansion  of  ma<ndible,  685. 
for  reducing  fractura  of  ramus  of 

jaw,  708. 
supporting,  after  res«ction,  32. 


1021 


1022 


INDEX 


Arlt's  theory  of  the  equator  of  de- 
pression, 891-896. 
Arthrodesis,  radio-ulnar,  476. 
Arthrotomy,  16. 

in  elbow  wounds,  134  et  seq. 
in  joint  wounds,  10. 
indications  for,  13. 
supporting  apparatus,  after,  32. 
Articular  comminuted  fractures,  7. 
Articular  fractures,  types  of,  6,  9. 
Artificial  dilatation  of  socket,   for 
prosthetic  purposes,  996. 
Artificial    eye,    939-942,    944-945. 
951-952,  965. 
preparation  of  orbit  for,  995. 
leg,  sometimes  preferable,  16. 
teeth  and  plate,  659  et  seq. 
Asepsis,  in  shoulder  wounds,  107. 
Asphyxia,    caused    by    descent    of 
tongue  into  pharynx,  663. 
Assessment    of    disablements,    by 
fracture  of  mandible,  763. 
Astragalectomy,    after    treatment, 

248. 
Astragalus,  fractures  of,  241. 
Asymmetry,  facial,  characteristics 

of,  638. 
Atrophy  of  the  eye,  926,  941. 
Aura,  sensory,  963,  968. 
Autopyo vaccine,  99. 
Avulsion  of  the  optic  nerve,  811- 
812,  826,  860-861. 

B.  serogenes  capsulatus,   cause  of 

gas  gangrene,  299. 
Bacteria     concerned     in     infected 

fractures,  295. 
Bacteriologic    control    of    wound, 

Carrel-Dakin  method,  50. 
Base  hospitals,  cases  seen  at,  4. 
"Bayonet  leg,"  574. 
Berlin's  diagnosis  of  seat  of  orbital 

fracture,  781,  782,  972. 
Bernard,  Claude,  syndrome  of,  921. 
Bertherand  on  "Gunshot  wounds 

of  the  orbit,"  779-780. 
Bipp    (bismuth    iodoform   paraffin 

paste),  77. 
employment  of,  77  et  seq. 
Rutherford  Morrison's  Method, 

77. 
Blake's  splint,  522. 
Blepharoplastv,  939,  941-942,  950- 

954,  993-996,  1011. 
Blood-vessels,  lesions  of  the,  872- 

879.  See  Aneurism,  Hsem- 

orrhage,  etc. 


Bone,  division  of,  24. 
marrow,  affected,  301. 
death  of,  302. 
infection  of,  12. 
restoration  of,  997-1014. 
substance,  large  loss  of,  in  frac- 
tures of  mandible,  622  et 
seq. 
treatment  of,  345. 
Bones  of  orbital  cavity,  789  et  seq. 
Bonnet,  principles  of,  364,  368. 
Bony  and  cartilaginous  grafts,  re- 
sults, in  fractures  of  man- 
dible, 757  et  seq. 
Bony  graft  from  still-born  infant, 
761. 
in  treatment  of  wounds  of  jaw, 
735. 
Bony  surfaces,  occlusion  of,  27. 
Bony  union,  27. 
Boot,  with  lateral  supports,  32. 
Bosquette's    pelvi-pedial    support, 

525. 
"Bouche  du  chantre  de  village," 

654  et  seq. 
Bracelet,     leather,      for     support, 

32. 
Bracketed  appliance,  396. 
Brain,  foreign  bodies  in,  fracture 
of  orbit,  recovery,  968. 
injury  to,  959-960,  963,  965,  977, 
979. 
Bridge,     method     for     anchoring 
fragments  of  jaw,  713. 
removable,  662. 
Brilliant  green,  35. 
paste,  83-84-85. 
Bullet,  carried  18  years  in  frontal 

sinus,  811 . 
Bullet  extractor,  early,  778. 
Bullet  wounds,   long   range,   signs 
of,  279. 
of  joints,  7. 
Bullets,     conditions     of     wounds 

made  by,  7. 
Bursa,  interosseaous,  serous,  21. 

Callus,  formation,  352.  474. 

healthy,    essential    for    fracture 

union,  294. 
moulding  of,  326. 
pathological,  336. 
Capsule,  rupture  of,  884-885. 
Capsulo-periosteal  sheath,  preser- 
vation of,  20. 
Carrel's    apparatus,    modifications 

of,  57. 
Carrel's  distributing  tubes,  44,. 


INDEX 


1023 


Carrel-Dakin  method,  34  eA  seq. 
advantages  of.  38,  39. 
bacteriologic  control  of  wound, 

50  et  seq. 
employment  of,  in  various  types 

of  wounds,  47. 
closure  of  wound  after,  52. 
instillation  of,  46. 
modification  of,  by  Dimond  and 

McQueen,  57. 
rules  for  application  of,  54  et  seq. 
technical  precautions,  47,  48. 
Carrel-Dakin  solution,  strength  of, 

39. 
Carron  du  Villars   on    exophthal- 
mos, 872. 
Cartilage,  unmouldability  of,  27. 
Cartilaginous     grafts,     932,     947, 

1003.  1014. 
Cataract,  after  contusion  of  eye- 
ball, 883. 
Cataracts,  traumatic,  882-885,  985, 
988-990. 
operation  on,  988. 
Cavalie's  dictum  on  treatment  of 
fractured  niandible,  670. 
Cavalie's  technique  in  bone  graft- 
ing, 756-757. 
Cellulitis,  877-878. 
Cerebral    substances,    loss    of,    by 
fractures,    959-960,    963, 
965,  977.  979. 
Cervical    sympathetic,    section    of 

the,  921-924. 
Chauvel  on  orbital,  fractures,  783- 

784. 
Chloramin   paste,    application    of, 
63. 
preparation  of,  63. 
Chloramin     solution,^    preparation 

of.  62. 
Chlorinated    eucalyptol.    prepara- 
tion of,  60. 
Chlorinated   paraffin  oil,   prepara- 
tion of,  60. 
"Choked  disc,"  964. 
Chopart's  operation,  261. 
Choroid  lesions,  852,  891  et  seq. 
clinical  laws  relating  to,  905. 
laceration  by  concussion,  831. 
by    laceration     and     contu.sion, 

828-829. 
localisation  of  injury,  908. 
mixed  lesions,  907. 
rupture  by  contusion,  900-904. 
rupture  by  grazing,  853. 
various     causes    and    kinds     of 
lesions,  891-899. 


Choroidal    haemorrhages    and    de^ 

tachment,  909. 
Choroidal  rupture,  892-894. 

indirect  896  et  seq., 
Choroido-retinitis,  a  lesion  charac- 
teristic   of   present    war, 
1016. 
morbid  type  of,  1016. 
ophthalmoscopic  appearance  in, 

912. 
traumatic,    proliferating,    910  et 
seq. 
Cleansing,  immediate,  essential  in 
treatment     of     fracturesv 
314. 
Clinical  course  in: 

fracture  of    humerus,    neck    o.f, 
378. 
shaft    of    humerus,   408. 
subdeltoid  fracture,  401. 
supracondylar  fracture,  434. 
fractures  of  forearm  above  elbow 
joint,  442. 
just  above  wrist,  461. 
^shaft,  448, 
fracture  of  shaft  of  radius,  466. 
lower  radial  epiphysis,  477. 
fracture  of  ulna,  485. 
fractures  of  femur,  shaft,  510. 
subtrochanteric,  495. 
supracondylar,  548. 
fractures  of  leg,  shafts,  555. 
supramalleolar  fractures,  570. 
Closure  of  jaws,  646. 
indemnity  for,  771. 
Clothing  particles,  carried  by  pro- 
jectile, 1. 
Collargol.  use  of,  in  .wounds,  76. 
"Colmatage,"  991. 
Colon,  rupture  of,  187. 
Commissural  nerve,  794. 
Complete     mandibular     fractures. 

602-603. 
Complications    of    the     eye.     970- 

992. 
Conclusions  in  regard  to  the  eye, 

1015-1015. 
Concussion  lesions  of  eye,  1015. 
Conjunctival  culs  de  sac.  restora- 
tion of,  994-996. 
Consolidation,  409. 

delayed,  383. 
Contact  lesions  of  eye,  1016. 
Contamination     of     wounds,     ex- 
tirpation of.  36. 
Contusions  of  the  globe.  852-853, 
882-885. 


1024 


INDEX 


Correction  of  deformity  of  jaw, 
mechanical  means  for,  672 . 

Cranial  bones,  origin  of,  793. 

Cranial   cavities,    lesions   of,   with 
orbital  fractures,  959. 
fractures,  807-810. 

Cranium,  vertebral  theorj'^  of  the, 
793. 

"Crank"  devised  by  Villain, 
mechanism  of,  in  frac- 
ture of  jaw,  718-719. 

"Cranks,"  types  of,  720. 

Crushing  of  limb,  6. 

Curetting,  essential,  348.    _ 

Cutaneous  anesthesia,  638-639. 

Cyst,  meningeal,  947,  949. 

Dakin  solution,  alkalinity,    Lyle's 
test  for,  42. 
apparatus  for,  43 
with  boric  acid,  41. 
without  boric  acid,  40. 
Damage    to    face,    by    fracture    of 

mandible,  630. 
Death,  after  fracture  of  orbit,  781. 
"Debridement,"  297. 
Delageni^re's     method     of     bone 

graft,  757. 
Delbet's  apparatus,  356,  417,  538, 

564. 
Delbet's    pyoculture    method,   35, 

36,94-95. 
Delens,  on  fractures  of  the  orbit, 

784. 
Delorme  on  orbital  fractures,  786, 
810. 
on  removal  of  splinters,  971. 
Demarquay    on    orbital    effusions, 
873. 
on  orbital  wounds,  780-781. 
De  Monacho  on  orbital  fractures. 

787. 
Dental  adjustment,  normal,  587. 
Descent  of  tongue  into  pharynx, 

663. 
Destruction       of       eyeball,       and 
neighboring  cavities,  946 
et  seq. 
" Detache-tendon"  of  Oilier,  23. 
Detachment  of  choroid,  905-906. 

of  retina.    aScc  Retina. 
De  Weeker   on   choroidal   lesions, 
898. 
on  effects  oL  haemorrhage,  865- 

867. 
on  orbital  fractures,  782. 
on  orbital  haemorrhage,  869. 
on  treatment  of  fractures,  971. 


Dialysis  of  iris,  887-890. 
Dichloramin-T,  35. 
employment  of,  61. 
in  oil  method,  58,  62. 
method  of  preparing,  59. 
Diplopia,  844-846,  931,  933,  956. 
Direct  fractures  of  orbit,  806. 
Disablements,    assessment    of,    in 
fractures     of     mandible, 
763  et  seq. 
Disinfection,     of    open     fractures, 
314  et  seq. 
of  soft  parts,  343. 
Displacement,  290. 
lateral,  311. 
various  types  of,  312. 
Distributing  tubes,  Carrel's,  44. 
Division  of  one,  24. 
Donaldson's  method,  100. 
Drainage,  27. 

by  esquillectomy,  334. 
Drapier's  apparatus,  as  substitute 

for  humerus,  274. 
Dressings,  414. 
bad  practices.  29. 
in  fracture  of  thigh,    534    et  seq. 
of  joint  wounds,  28. 
over  voluminous,  29. 
points  in,  349. 
suitable  time  for,  29. 
Duchange's  apparatus  for  expan- 
sion of  mandible,  687. 
Dupuy-Dutemps    on    hsematoma, 

8'  '  867. 
Dupuytren,    on    orbital    fractures, 
780. 
on  wounds  of  the  orbit   (1854), 
780. 
Dynamics,     laws    of,     applied     to 
orbit,  797. 
of  the  orbit,  797-801 . 
Dyspnoea,  112. 

Early   treatment,    indications    for, 
in: 
fracture  of  the  humerus,  neck, 
389. 
middle  of  shaft,  411. 
sub-deltoid  fracture,  402. 
supracondylar  fracture,  434. 
fractures     of     forearm,     above 
elbow  joint,  444. 
just  above  wrist,  461. 
shaft,  450. 
fracture  of  shaft  of  radius,  468. 
of     lower     radial     epiphysis, 
479. 
fracture  of  ulna,  487. 


INDEX 


1025 


Early  treatment,    indications   for, 
fractures    of  femur,    sub- 
trochanteric, 496. 
shaft,  512. 
supracondylar,  548. 
fractures  of  leg,  shafts,  556. 
supramalleolar  fractures,  571- 
Ecchymosis    of    the    conjunctiva, 

875-876,  903. 
Ectropion,  cicatricial,  954. 
Effusion  from  base  of  cranium,  798. 

intra-orbital,  872-879. 
Elbow,  wounds  and   fractures  of, 
129  et  seq. 
after  treatment,  155  et  seq. 
evacuation  of  patients  with,  160. 
late  after  treatment,  162  et  seq. 
operative  technic  in,  149  et  seq. 
profuse-,  suppuration     in      later 

cases,  164-165. 
types  of,  131. 
Electro-magnet,  use  of,  981. 
Encyclope<iie    francaise     d'Ophtal- 

moloqie,  786. 
Endothelial  cells  of  synovial  mem- 
brane, 20. 
Enophthalmos,  849-850,  917-921, 
921-925,  926-937. 
falge  and  true,  928-929. 
nervous  theory  of,  923. 
symptoms    and    diagnosis,    934 

et  seq. 
traumatic,  917,  931,  937  et  seq. 
treatment  of,  937. 
Enucleation,    cases   of,    933,    939- 
943,     945-950,     954-955, 
965,     976-977,     984-985, 
987. 
early  practice  of,  781. 
of  eye,  976. 
Epileptiform  attacks,  accompany- 
ing, fracture  of  orbit  with 
neuritis,  979. 
Epiphyses,  fractures  of,  25. 
Epithelial    lesions,    superficial,    of 

eyeball,  882. 
Equator  of  depression  in  rupture 

of  choroid,  791-796. 
Esquillectomy,  10,  412. 

advantages  of,  316-317  et  seq. 
and  amputation,  choice  between, 

340. 
counter-indications  to,  339. 
criticisms  of,  319. 
details  of,  345. 
in  hip  wounds,  188. 
in  shoulder  wounds,  106. 


Esquillectomy,    in    wrist   wounds, 
172. 
indications  for,  14,  .331. 
predisposing    to    pseudarthoris, 

disproved,  .322. 
prophylactic,  315. 
sub-periosteal,  328  et  seq. 
Ether  or  chloroform,  choice  of,  for 
operations    on    fractured 
jaws,  741 
Ethmoid itis,  887. 
Eusol  and  Eupad,  67  et  seq. 
Evacuation  of  patients  after' 
shoulder  wounds,  124. 
elbow  wounds,  160. 
wrist  wounds,  180. 
hip  wounds,  197. 
knee  wounds,  225. 
ankle  wounds,  252. 
foot  wounds,  268. 
Evisceration,  976. 
Exophthalmos,  837,  839,  841-84:2, 
858 
consecutive,  872,  875-879,  920- 

921,  965. 
reduction  of,  975. 
Expulsive  haemorrhage,  905-906. 
Extension,  by  metallic  loop,  359. 
by  sliding  appliances,  360. 
choice  of  position  for,  in  fracture* 

of  thigh,  530-531. 
continuous,  by  weights,  357. 
in   fractures  of  the  femur,  519 

et  seq. 
methods  of  effecting,  4J3. 
Exterior  orbital  margin  and  wall, 
fractures    of,    treatment, 
974. 
External  wall  of  orbit,  fractures  of, 

811-812,  974. 
Extravasation,  intra-orbital,  774— 

775. 
Extrinsic    and    intrinsic    muscles, 

lesions  of,  879-882. 
Eye,  concussion  lesions  of,  1015. 
conclusions  in  regard  to,  1015. 
destruction   of,   938-969. 

and  neighboring  cavities,  946. 
in  fractures  of  orbit,  938,  975. 
enucleation  of,  976. 
lesions  of  the,  882-899.     Se-e  aho 

Case  Reports, 
preservation  of  the,  813-827. 

in  orbital  fracture,  813,  974. 
ruptured,  treatment  of,  983. 
Ej'elids,    restoration    of   the,    942, 
993-996. 


1026 


INDEX 


Facial  asymmetry,  after  fracture  of 

mandible,  637. 
Facial    bbnes,     fractures    of    the, 

957. 
Fall,  loss  of  vision  after,  864. 
Fatal  results,   rare,   in  wourds  of 

face,  586. 
Faulty  union,  310. 
Femur,  fractures  of  the,  494. 
fractures  of  shaft  of,  507. 
separation  of  head  of,  185. 
Ferrier's  cachets,  675. 
Fingers,  amputation  of,  174. 
Finochietto's  stirrup,  359. 
Fissures,  of  orbit,  809,  810. 

occurring  in  fractures,  284. 
Fistula,  901. 

Fixation      apparatus,      types     of, 
382. 
by  suspension,  379. 
in  fractures  of  the  femur,  517. 
Flail  arm,  399, 
Flail-elbow.  167. 
Flail-like      limb,      after     shoulder 

wounds,  128. 
Flavine,  (acri- and  pro-fiavine) ,  80 

ei  seq. 
Flavine  and  Bipp,  35. 
Foot,  amputation  of,  244. 
malposition  of,  533. 
solidity  of,  preserved,  243-244. 
wounds  and  fractures  of,  255. 
Foramen,    optic,    fracture    of    the, 
809. 
the  supra-orbital,  790. 
Forcible  reduction,  568. 
Forearm,  fractures  of,  439  et  seq. 
Foreign  bodies  in  antrum,  necessity 
of  extraction  of,  980. 
in  the  bram,  963,  965-96S,  970. 

977-978. 
in  the  eye,  983,  986-987. 
in  orbit,  removal  of,  980-9S2. 
various       writers      on,       780 
et  seq. 
not  necessary  always  to  remove, 

980. 
removal  of,  essential,  315. 
Fossa,  right  temporal,  wounds  of, 

899-900. 
Fossse,  nasal,  fractures  and  wounds 

of  the,  788,  902. 
Fractures   and   wounds,   of  ankle, 
234  ei  seq. 
of  elboM".  129  et  seq. 
of  foot,  255 
of  hip,  184  et  seq. 


Fractures    and    wounds,    of    knee, 
201  et  seq. 
of  the  shoulder,  102  et  seq. 
of  wrist,  170  et  seq. 
Fractures,     as     regards    operative 
interference,  age  in,  737. 
by  contre  coup  does  not  exist, 
1015. 
as     sepsis     first     essential     in 
treatment  of,  314. 
"by  contact,"  597. 
comminuted,  articular,  7. 
caused  by  other  projectiles  than 

long  range  bullets,  277. 
chief  types  of,  281. 
compound,  treatment  of,  8. 
conservative  treatment  of,  gen- 
eral principles,  313  ei  seq. 
disinfection  of,  314  et  seq. 
gunshot,  reduction  of,  353  et  seq. 
immediate  results  of,  292  et  seq. 
immobilization  of,  362  et  seq. 
implicating  cavities  neighboring 
upon  the  orbit,  946-948, 
976-980. 
infected,  278,  294,  297,  304-305, 
308-309. 
bacteria  concerned  in,  295. 
involving  joints,  1  et  seq. 
of  astragulus,  241. 
of  elbow,  types  of,  131-132. 
of  femur,  205,  494  et  seq. 

shaft  of,  507. 
of  fibula,  head  and  necl^,  577. 
shaft,  578. 
types,  ..    ^. 
of  the  forearm,  439  et  seq. 

essential   points   in   anatomy, 

440. 
types,  441. 
of  humerus,  385  et  seq. 
complicated,  111. 
shaft  of,  406. 

neck  of ,  clinical  course,  387. 
physiological    features    of, 

386. 
types,  385. 
of  joints,  resection  of,  12. 
of  leg,  554  et  seq. 

shaft,    appliances    for,    560    et 

seq. 
types,  554. 
of  lower  limb,  multiple,  581. 
of  malleolus,  579. 
of    mandible,    alveolar    border, 
601. 
anterior,  676  et  seq. 
anterior,  old,  682. 


INDEX 


1027 


Fractures,    of   mandible,   at  angle 
of  jaw,  616,  641. 

mechanical  treatment,  703. 
at  ramus,  617,  642,  706. 

closure  of  jaws,  646. 
due  to  ankylosis,  648. 

complete,  602-603. 

complete,  anterior,  603. 

complete,  lateral,  609  e.t  seq. 

complications  of.  663-664. 

coronoid  process,  601. 

diet  suitable  for,  676. 

double  and  multiple.  620  et 
seq. 

etiology  of.  597. 

expansion  apparatus.  685. 

facial  asymmetry,  637. 

incomplete,  600. 

indemnity  for,  767'e<  seq. 

inferior  border,  001. 

intermaxillary  anchorage,  689. 

medium,  anterior,  immobili- 
zation of,  681. 

old,  640-641. 

operative  technic,  736  ei  seq. 

periods  of  treatment,  670. 

preparatory  treatment,  675. 

radiography  in,  644. 

recent,  633  et  seq. 

stages  of  treatment,  629. 

temporo  -  mandibular     joint.. 
601. 

time  for  operation,  758. 

types,  599  et  seq. 

usually  compound,  624. 
■of  orbit,  777  et  seq. 

accompanied  by  destruction 
of  neighboring  cavities, 
946  et  seq. 

complications,  treatment  of, 
970  et  seq. 

direct,  806. 

eye    preserved,    no    retention 
of  foreign  body,  813-837. 
foreign  body  retained,   837 
et  seq. 

general  considerations,  upon, 
802  et  seq. 

historical  view,  777  et  seq. 

implicating  neighboring  cavi- 
ties, 976  et  seq. 

indirect,  804. 

intracranial  complications, 
979. 

pathogenesis,  807  et  seq. 

reparative  surgery  in,  993  et  seq. 


Fractures,    of    orbit    some    recent 
writers  on.  785. 
statistics.  783. 
statistics,  in  present  war.  802 

et  seq. 
with    destruction    of    eyeball. 

938  et  seq. 
with  preservation   of  eyeball. 

813. 
without  injury  to  optic  nerv^e. 
805- 
of  patella.  205 
of  posterior  tarsus.  J43. 
of  radius,  465. 

of  shaft,  general  study,  277  et  seq. 
of  tibia.  205,  574. 

extra  articular.  574-575. 
lower  end,  576. 
shaft,  575. 
of  trochanter,  186. 
of  ulna,  484  et  seq. 
of  upper  limb,  multiple.  490  et 

seq. 
operative  technic  outlined,  316. 
parietal,  excision  of,  11. 
pathological  anatomy  of,  280  et 

seq. 
pathological   changes   following, 
294.    297,   304-305.   308- 
309,  397  et  seq,  408,  458. 
574. 
produced  bj'^  long-range  bullets. 

277. 
supra-condylar,  433. 
supra-malleolar,  569  et  seq. 
time  of  operation  for.  333  et  seq. 
treatment  of.  1  et  seq.,  277  et  seq. 

essential  points  of,  313,  314. 
with  large  loss  of  bony  substance. 
622  et  seq. 
Fragments,  types  of,  283. 
Frontal  sinus,  lesions  of,  with  or- 
bital fractures,  958.  959, 
980. 
Function,    recovery    of.    essentials 

for,  22. 
Functional   result,    aim   of   opera- 
tion, 142: 

Galezowski    on    orbital    fractures. 

782. 
Gas  gangrene,  298  et  seq. 

does  not  accompany  wound  of 

face,  632. 
Gastrostomy     not     mdicated.     in 

fractures      of     mandible. 

666. 
Gigli's  saw,  use  of.  24. 


1028 


INDEX 


Globe  of  eye  preserved,  814. 

<jronin  on  hsematoma,  866-867. 

<5rafts,    932,    940,    947,    952,    995, 
997-1014. 
bony,     results,     in     fracture    of 
mandible,  751  et  seq. 

Guyon's  supra-malleolar  amputa- 
tion, 261. 

Hsemarthrosis     with     wounds     of 

knee,  7- 
Haematic  pigment,  diffusion  of,  1017- 
Hsematoma  of  the  sheaths  of  the 
optic  nerve,  865-871. 
in  the  newborn,  874. 
theory  of,  1017. 
Hsemianopia,  804-805. 
Haemorrhage,  by  contre  coup,  875. 
choroidal,  905-906. 
into  optic  nerve,  866-867. 
intra-orbital,  872-879. 
macular,     820-821,     839,     862, 

870-871. 
retinal,  870. 
secondary,  complicating  lesions 

of  jaw,  663. 
secondary,    grave    symptom    in 
fracture  of  mandible,  632. 
traumatic  into  orbit,  872  et  seq. 
Hsemostasis,  essential,  349. 
Hand,  total  amputation  of,  173. 
Hawley's  extension  apparatus,  522. 
Healing  wound,  with  Carrel-Dakin 

method,  50. 
Heliotherapy,  90,  157.  * 
action  of,  351. 
marvellous  results,  29. 
Hennequin's  sling,  521. 
Hey's  brilliant  green,  35. 
Hey  Groves  apparatus,  523. 
Hip,  wounds  and  fractures  of,  184 

et  seq. 
Hip    wounds,    operative    technic, 
190  et  seq. 
patients  seen  late,  199-200. 
post  operative  treatment,  193. 
Hippocrates,  on  foreign  bodies  in 
the  orbit,  777. 
on  fractures  of  the  internal  mar- 
gin and  wall,  973. 
Hirtz's  compasses,  13. 
History  of  orbital  fracture,  777-788. 
Homer  on  orbital  fracture,  777. 
Humerus,  fractures  of,  385  et  seq. 
fractures  of  the  neck,  385. 
fracture  of  shaft,  406. 
fractures  of,  complicated,  111. 
tj'pes  of  injuries  of,  115. 


Hydrostatic  pressure,  cause  of 
fracture  of  orbit,  not 
proven,  807. 

Hygroma,  formation  of,  21. 

Hypertonic  solutions,  71  et  seq. 

Hypochlorite     solutions,     employ- 
ment of,  45. 
objections  to,  58. 

Hypochlorites,  35. 

Hypo  chlorous  acid  preparations, 
Eusol  and  Eupad,  67. 

Immobilisation,  417. 

apparatus  for  lateral  fracture  of 

mandible,  700. 
ideal,  365. 
limited,  378. 
of  fractures,  362. 
of  jaw,  easy,  593. 
of  jaws  in  occlusion,  705. 
of  joints,  28. 

principles  governing,  364. 
subsequent  treatment,  384. 
"Incomplete"     mandibular     frac- 
tures, types,  601-602. 
Indemnity  for  loss  of  teeth,  765. 
Indirect  fractures,  of  orbit,  804. 

theory  of,  807-812.     • 
Inferior  dental  nerve,   section  of, 

639. 
Inferior  orbital  margin  and  wall, 
fractures  of,  treatment,  973. 
Inflammatory  complications,  889- 

890. 
Injury,    to    brain,    accompanying 
fracture  of  orbit,  785. 
to  eye,  according  to  direction  of 
projectile,  813-814. 
in  middle  ages,  778. 
to     soft     parts,     accompanying 
fractures,  288  et  seq. 
Insolation,  effects  of,  30. 
Intermaxillary  anchorage,  method 

of,  689. 
Internal  orbital  margin  and  walU 
fractures    of,    treatment, 
973. 
Intra-cerebral  foreign  bodies,  with 
fracture  of  orbit,   recov- 
ery, 968. 
Intra-cranial  complications  of  or- 
bital fractures,  979. 
Intrinsic  muscles,  lesions  of,  879 

882. 
Inversion  of  the  iris,  890-891. 
lodated  starch,  80. 
Iridio-capsulotomy,  989. 
Irido-chorioiditis,  962. 


INDEX 


1029 


Iria,  injuries  of,  887  et  seq. 
with  haemorrhage,  889. 
Iritis  of  the  aged,  889,  890- 

Jaboulay's  arthrotomy,  207. 
Jaboulay's  method  of  drainage  of 
supra-patellar  pouch,  210. 
Javelle  water,  in  treatment  of  war 
wounds,  65. 

preparation  of,  66. 
Joint  fractures,  resection  of,  12. 
Joint  infection,  types  of,  2  et  seq. 

with  toxic  symptoms,  3. 
Joint,  new,  development  of,  21. 
Joint  wounds,   evacuation   of  pa- 
tients, 33. 

gravity  of,  1,  4. 

uncomplicated,  2. 
Jointed  splint,  529. 
Joints,  immobilisation  of,  28. 

wounds  of,  1  et  seq. 
"Jumping  the  bite,"  593. 

Keratitis,  827,  840. 

Kernig's  sign,  877,  977. 

Knee,  joint  lesions,  types  of,  208 

et  seq. 
late  pathological   conditions  of, 

229  et  seq. 
wounds,   and  fractures   of,   201 

et  seq. 
Kronlein's  operation  for  removal  of 

foreign    body    from    eye, 

838,  840,  845,  981,  982. 

Laceration  of  nerves  and  muscles, 

852. 
Lacrymal  fossae,  791. 
Lambotte  plate,  546. 
Landolt  on  orbital  fractures,  782. 
Larrey,  observations  of  (1832), 779. 
Late    pathological    conditions    of 
ankle,  253. 
elbow,  164. 
foot,  269. 
hip,  199. 
knee,  226. 
shoulder,  126. 
wrist,  183. 
Late  stages  and  results  of: 

fracture   of   humerus,    neck   of, 
393  et  seq. 
sub-deltoid  fracture,  406. 
fracture  of,  shaft  of,   humerus, 
429  et  seq. 
supracondylar  fracture,  437. 
fracture  of  forearm,  above  elbow 
joint,  445. 
shaft,  456. 
fracture  just  above  wrist,  463. 


Late  stages  and  result  of:  fractures 
of  shaft  of  radiu's,  473. 
fracture  of  lower  radial  epiphy- 
sis, 481. 
fracture  of  ulna,  488. 
fracture  of  femur,  sub-trochan- 
teric,  504. 
shaft,  541. 
supracondylar,  551. 
fracture  of  leg,  shafts,  564. 
of  supramalleolar  fractures,  573 
Laws  governing  the  affections  of 
the   visual    apparatus    in 
injuries  of  the  orbit  with 
preservation   of  the  eye* 
ball,  803-804. 
Leclerq's  appliance,  419. 
Leclorinche  and  Vallee,  polyvalent 

serum  of,  35. 
Leg,  fractures  of,  554. 
Lens,  opacification  of  the,  882-885. 
Lesions  of  eyeball,  882  et  seq. 
Lesions  of  optic  nerve,  859. 
Loss  of  teeth  complicated  by  frac- 
tures of  alveolar   border 
of  mandible,  765. 
Loss  of  vision  after  fall,  864. 
Lower  limb,  esquillectomy  of,  343. 

multiple  fractures  of,  581. 
Luxation  of  lens  of  eye,  885,  886. 
Lyle's  test  for  alkalinity  of  Dakin 

solution,  42. 
Lymphagogic  agents,  71  et  seq. 

Macular  lesions,  833,  850-852. 
Magnesium  chloride,  74. 
Magnesium  hypochlorite  solution, 

65. 
Magnesium  sulphate,  86. 
Magnus  on  effects  of  haemorrhage, 

865. 
Mai  conitial,  963. 
Malar  bone,  elevation  of  the,  973. 

injuries  frequent,  811. 
Malar  canal,  792. 
Malleolus,  fractures  of,  579. 
Malocclusion,  636  et  seq. 
treatment  of,  727  et  seq. 
types  of,  in  united  mandibular 
fracture,  652. 
Malposition    of    jaw    in    old    frac- 
tures, 620. 
Mandible,    apparatus    for    expan- 
sion of,  685. 
fractures  of,  anterior;   posterior; 

vertical,  599. 
movements  of,  592. 
surgical  advantages  of,  593-595. 


1030 


INDEX 


Mandibular    fractures,    stages    of 

treatment,  629. 
table  of  treatment,  670. 
Mandibular      lesions,      immediate 

treatment  of,  662. 
Mandibular  rigidity,  essential  for 

mastication,  592. 
Martin,  Claude,  work  of,  585. 
Martin's  formula,  versus  modern 

practice,  596. 
Martin's  principles,  590. 
Mastication,       dependent       upon 

dental  adjustment,^89. 
Masticatory  exercises,  670. 
Maxillary  antrum,  lesions  of,  with 

orbital  fracture,  948. 
Maxillo     -     facial         department, 

patients       returned       to 

arrniy,  736. 
Mechanical      therapy,      in      joint 

woimds,  cautions  regard- 
ing, 32. 
Mechanical  treatment  of  fracture 

of  mandible,  659. 
problems  of.  666  et  seq. 
Mechanism      to      bring      forward 

posterior      fragment,      in 

fracture  of  mandible,  696- 

697. 
Medulla,  condition  of,  in  fractures, 

285. 
Medullary  canal,  danger  in,- 315. 
Membranes  of  eve,   affections  of, 

886.  906,  917. 
Menacho      on      "heridas      orbito- 

oculares     en     cirugia    de 

guerra,"  787. 
Meningitis,  967.  977. 
Meningo-encephalitis,    after    frac- 
ture   of    orbit,    967-968, 

972.978-979. 
Mental   region    of   jaw.   vasculari- 
zation of,  690. 
Metacarpal  fractures,  182. 
Metal  splints.  368. 

limitations  of,  28. 
Methyl  violet.  86. 
Missiles  within  join,t. removal  of, 11 . 
Mobilisation,  30. 

Olliers  dictum  regarding,  31. 
Morestin,     reparative     operations 

by,  1004-1007. 
Morphine  in  shock,  215. 
Morrison's  method  (Bipp),  77. 
Mortality     statistics     in     wounds 

of  face.  586. 
Mouth-opener,  mechanical,  732. 
Moynihan's  views  on  Bipp,  79. 


Muller's     muscle,     paralysis     of, 

919-920,  922. 
Multiple  fractures  of  jaw,  620. 
Multiple  fractures  of  lower  limb 

581. 
Multiple  fractures  of  upper  limb, 

490  et  seq. 
Multiple  joint  wounds,  272  et  seq. 
Muscle  destruction,  296. 
Muscles    dissociated    by     femoral 

fracture,  508. 
Muscles,  orbital  ball  in,  863. 

traumatic  lesions  of,  879-882. 
Mydriasis,  881,887. 
Myopia,  904-905. 
Myotonic  constriction.  654  et  seq. 
of     maxillae,     mechanico-thera 

peutic  treatment  of,  730 

et  seq. 

Nerve  lesions,  290. 

motor  nerves,  854-856. 

optic   nerve,    intra-ocular,    860- 
861. 
Nerves,     lesions    of    the    sensorv 
nerves.  856-857. 

sympathetic  nerves,  857-859. 
Neuritis,  optic.  901,  946. 

retro-bulbar,  957. 
Nov6-Josserand's  method,  476. 

Occular    complications    of    orbital 
fracture,     treatment     of, 
983,  et  seq. 
Old   lateral   fracture   of  mandible, 

701. 
Olecranon,  fractures  of,  136-137. 
Oilier,  arthrotomy,  207. 
method,  13.  18. 
orthopedic  results,  244. 
pelvi-cervical  support,  194. 
results,  143. 
rugines,  23,  346. 
Ombredanne,  method  of,  476. 
Operative   indications,    as   regards 

age  of  fracture,  737. 
Operative  technic  in 
shoulder  wounds,  112. 
elbow  wounds,  149. 
wrist  wounds,  175. 
hip  wounds,  190. 
knee  wounds,  216. 
ankle  wounds,  245. 
foot  wounds,  262. 
fractures  of  humerus,   neck  o 
389. 
subdeltoid  fracture,  402. 
shaft  of,  412. 


INDEX 


1031 


Operative  technic  in 

supra-condylar  fracture,  435. 
fractures  of  forearm  above  el- 
bow joint,  445. 
just  above  wrist,  462. 
of  shaft,  451. 
fracture  of  shaft  of  radius,  470. 
fracture  of  lower  radial  epiphy- 
sis, 479. 
fracture  of  ulna,  486. 
fracture  of  femur,  sub-trochan- 
teric,  497. 
shaft,  514. 
supracondylar,  550. 
fractures  of  leg,  shafts,  557. 
of  supra  malleolar  fractures,  572. 
■Operations,    preparation    for,     in 
fractures     of     mandible, 
739. 
suitable  time  for,  in  fractures  of 

mandible,  738. 
>on  fractured  mandible,  details  of 

technic,  742  et  seq. 
on  joints,  general  technic,  18  et 

seq. 
primary,  10. 
secondary,  16. 
Ophthalmia,   sympathetic,   983   et 

seq. 
Ophthalmia,     sympathetic,     enu- 
cleation of  globe  in,  945- 
946  (983-988). 
treatment  of,  986. 
Ophthalmoplegia,  total,  857-859. 
Ophthalmoscope,  shows  lesions  of 
eye  after  concussion,  1015. 
Ophthalmoscopic     examination. 

See  Case  Reports. 
Optic  atrophy,  843-844,  849,  858, 

863. 
Optic  nerve,  atrophy  of,  817,  822, 
828. 
avulsion  of,  lesions  of,  826,  852. 

See  Nerves. 
hsematoma  of  sheaths,  865. 
lesions  of,  859. 

behind  entry  of  vessels,  862. 
direct  injuries,  862-863. 
indirect,  863-865,  870-871. 
retro-bulbar,  861-862. 
Orbit,  bones  of  the,  789. 

fractures   of   the,   dynamics  of, 
797-801. 
etiology  of,  802-806. 
frequency  of,  783-784. 
history  of,  776-787. 
resistance  of  orbit  to,  795-796. 
protective  role  of,  793. 


Orbit,    bones    of    the,    traumatic 
haemorrhages  into,   872. 
vulnerability  of,  798  et  seq. 
Orbital  cavity,  788  et  seq. 
anatomy  of,  788. 
conformation  of,  788  et  seq. 
margin    and   wall,    fractures   of 

the,  971-972. 
resisting  power  of,  795  et  seq. 
Orbital  cellulitis,  876. 

death      following,      878. 
Orbital    fractures,    direct,    do    not 
occur  by  radiation,  809. 
direct  treatment  of,  971. 
implicating  neighboring  cavitieb, 

976  et  seq. 
in  war  are  direct  fractures,  1015. 
pathogenesis,  807. 
reparative  surgery  in,  993  et  seq. 
Orbital  margin  and  walls,  inferior, 
external      treatment      of 
fractures  of,  971  et  seq. 
internal,  970  et  seq. 
superior,  970  et  seq. 
Orbital  muscles,  paralysis  of,  SSO'- 
881. 
repair  of  damage  to,  997. 
Orientation    of   mandibular    arch, 

670. 
Orthopedic  results,  in  fractures  of 

astragulus,  243-244. 
Os  calcis, gunshot  fracture  of,  236. 
Ostectomy,   oblique,   by  S^bileau, 

653. 
Osteitis,' focal,  12. 
Osteogenesis,  process  of,  21. 
Osteogenetic  cells,  death  of,  307. 
Osteogenetic    layer,    proliferation 

of,  20. 
Osteomyelitis,  300. 
Osteo-synthesis,     in     fracture     of 
mandible,  734,  748  et  seq. 
Otis  on  orbital  fractures,  784. 
Over-riding  of  fragments,  291. 
Ozone  treatment  of  wounds,  93. 

Panophthalmitis,  946. 

Papilla,  traumatic  lesions  of  the, 

860. 
Paralysis,  of  external  rectus,  928, 

961. 
of  nerve  of  the  eye,  856. 
of  orbital  muscles,  880,  881. 
Paramedian  fractvu-e  of  jaw,  606-* 

608. 
Par6,  Ambrose,  on  injuries  to  eye, 

778. 
Parietal  fracture,  excision  of,  U~ 


1032 


INDEX 


Pari-papillary  rings,  865-866,  869, 

870. 
Patella,  frkcture  of,  205. 

removal  of   217. 
Pathogenesis  -  f  orbital  fractures, 

807       2. 
Pathology  of    fsual  disorders,  849 

et  seq. 
Pelvi-cervical     support,      Ollier's, 

194. 
Pelvi-pedial,  casing,  195. 

support  (Bosquette),  .525. 
Percy's  Manuel  de  Chirurgi6  d'ar- 
m6e  (1792),  quoted,  778, 
779. 
Periosteal  regeneration,  145. 
Periosteum,  condition  of,  in  frac- 
tures, 285  et  seq. 
infection  of,  305. 
Pes  equinus,  apparatus  for  correc- 
tion of,  562. 
Physiological  features  in : 

fracture    of    humerus,  neck    of, 
386. 
sub  deltoid  fracture,  400. 
shaft  of,  407. 

supra-condylar  fracture,  433. 
fractures  of  forearm  above  elbow 
joint,  442. 

just  above  wrist,  460. 
shaft,  446. 
fracture  of  shaft  of  radius,  466. 
fracture  of  lower  radial  epiphysis, 

477. 
fracture  of  ulna,  484. 
fracture  of  femur,  sub-trochan- 
teric,  494. 
shaft,  508. 
supracondylar,  547. 
fractures  of  leg,  shafts,  555. 
of      supramalleolar       fractures, 
570. 
Physiological  incisions,  19. 
Pigmentation,  900-901. 
Pigmented  ring  in  hsematoma,  865, 
867,    868,    869,    870-871, 
872. 
Pirogoff's    tibio-tarsal    disarticula- 
tion, .261. 
Plaster  appliances,  370  et  seq. 
continuous  extension,  376. 
errors  in  construction  of,  374. 
Plaster  bandages,  426. 
Plaster    casing,    for   immobilizing, 

28 
Plaster  gait,  358. 

Plugging,     instead     of     drainage 
tubes,  349. 


Polyvalent  serum,  35. 

treatment  of  wounds  with,  98- 
99. 
Position    of    foot,    in    fracture    of 

thigh,  533. 
Posterior    fractures    of    mandible, 

599. 
Posterior  tarsus,  fractiJre  of,  243. 
Post-operative  treatment : 
of  ankle  wounds,  248. 
of  elbow  wounds,  154. 
of  foot  wounds,  266. 
of  hip  wounds,  193. 
of  knee  wounds,  218. 
of  shoulder  wounds,  117. 
Preparatory  treatment  in  fractures 

of  mandible,  675. 
Proflavine,  preparation  of,  83. 
Projectile,    carrying   clothing  par- 
ticles, 1. 
direction  of,  in  relation  to  orbital 

injuries,  813-814. 
indirect  lesions  caused  by,  905. 
relation  of,  to  visual  disorders, 
1016. 
Pronation  and  supination  in  frac- 
tures of  forearm,  440. 
Prosthesis  after  mandibular  frac- 
ture, 670. 
Prosthetic  methods,  applied  after 
fractures    of   orbit,    with 
loss    of    substance,    1006 
et  seq. 
repeated     operations    necessary 
for  success,  1010. 
Proteolytic  phenomena,  results  of, 

335. 
Protovertebrae,      absence      of     in 

cranium,  793. 
Pseudarthrosis,  307,  399. 
lateral,  714  et  seq. 
not    caused    by    esquillectomy, 

322. 
of  jaw,  650  et  seq. 

treatment  of,  710  et  seq. 
of  ramus  of  jaw,  not  affecting, 
mastication,  709. 
with  loss  of  substance,  mech- 
anism for,  724-726. 
Pulmonary  injuries  accompanjnng 

shoulder  wounds,  112. 
Punctiform  wounds,  278. 
Pyoculture  method,  Delbet's,  36. 

Radiating  fractures,  808-810,  812. 

with  loss  of  sight,  864. 
Radiation,  not  usual  in  injuries  of 
orbital  cavity,  806. 


I 


INDEX 


1033 


Radiography,  in  case-record,  816, 
825-826,  830,  835-841, 
843,  846,  849,  857,  900, 
926,  932,  939,  943,  945, 
947-948,  950,  954,  956, 
963,  965,  967-968. 
in  cranial  fractures,  805-806. 
use  of,  in  mandibular  fracture, 

642  et  seq. 
small  value  of,  in  fractiires  of  the 
orbital  vault,  972. 
Radius,  fracture'of,  465  et  seq. 
Recovery  of  function,   essentials 

for,  22. 
Reduction,  forcible,  355. 

gradual,  356. 
Reed-blind  material,  569. 
Repair  of  damage  to  orbital  walls, 

997. 
Reparative  surgery  of  fractures  of 

orbit,  993  et  seq. 
"Reptilian  jaw"  deformity,  636. 
Resection,  10,  12,  13,  17. 
advantages  of,  138-147. 
after  treatment,  156. 
extensive,  109. 
indications  for,  26,  141. 
of  nerves  of  orbit,  857. 
of  shoulder,  109. 
of  elbow,  138. 
of  wrist,  179, 
of  hip,  189. 
of  knee,  212. 
of  ankle,  240. 
of  foot,  258. 
sub-periosteal,  15,  389. 

of  ankle,  172. 
supporting  apparatus,  after,  32. 
in  shoulder  wounds,  106. 
Rest,    necessity   of,    in   inflamma- 
tion, 30. 
period  of,  overdone,  31. 
Restoration,    of    bony    structures. 
See  Grafts, 
of  mandibular  arch,  670. 
Retention  bridges,  use  of,  693. 
Retina,  affections  of,  907. 
detachment  of  the,  828. 
haemorrhage,  829. 
lesions  of  the,  853. 

pure  and  mixed,  906-907. 
lesions,  varieties,  907. 
total,  926,  931,  962. 
traumatic  detachment  of,  915- 

917. 
treatment  of,  829. 
treatment     of     traumatic     de- 
tachment, 990-992. 


Retina,  double,  832-833. 
by  contact  lesion,  834-835. 
multiple  traumatic  lesions,  846, 
848,  900. 
Retinal  detachment,  operation  of 

choice  on,  991. 
Retinitis,  proliferans,  819, 824, 829- 
830,  901-903,  907-910. 
proliferating,  differentiation  be- 
tween,   and    choroido-re- 
tinitis,    traumatic    prolif- 
erating, 915. 
traumatic,  916. 
Rigidity  of  jaw,   versus  occlusion 

of  teeth,  589-590. 
Rohmer  on  orbital  fractures,  786. 
Rollet  on  orbital  fractures,  786. 
Rugins,  of  Oilier,  23,  346. 

use  of,  345. 
Ruptures  of  sclerotic,  not  seen  in 
war,  1017. 

Salt  pack  method  of  wound  treat- 
ment, 72. 
Salt  sacks,  packing  for  wounds,  70. 
Sauvez'   therapeutic  classification, 
in  mandibular   fractures, 
673. 
Sclerotic,  rupture  of  the,  886,  893. 
"Sebileau's  serpent-jaw,"  605. 
Segmental  theory  of  cranium,  794. 
Sencert's  appliance,  521. 
Sepsis,  309. 
Septic  phenomena,  suppression  of, 

106. 
Septicemia,  297. 

accompanying  synovial  injury,  2. 
Serotherapy,  35. 
Serum,  polyvalent,  35. 

treatment     of     Leclanche     and 
VaUte,  96-97. 
Shaft,    fractures,   causes   of,   from 
point    of   view    of    treat- 
ment, 277. 
general  study,  277  et  seq. 
produced  by  long-range  bullets, 
277. 
Shock   accompanying   crushing  of 
limb,  6. 
accompanying  fracture  of  femnr, 

514. 
accompanying  hip  wounds,  188. 
immediate  treatment  of.  333. 
Shortening,  due  to  vicious  union, 

545. 
Shoulder,  lesions,  location  of,  102. 
wounds  and   fractures,  anatom-^ 
ical  types,  102. 


1034 


INDEX 


Shoulder,  wounds  and  fractures  of, 
casings  for,  120  et  seq. 
esquillectomy     and     sub-perios- 

teal  resection,  106. 
evacuation     of     patients     with, 

124. 
flail-like  limb,  after,  128. 
operative  technic,  112  et  seq. 
persistent  sinus  in,  127. 
post-operative  treatment  of,  117 

et  seq. 
practical  steps  in  treatment  of, 

107,  108. 
simple  immobilisation  of,  105. 
treatment  of  patients  seen  late 
or  after  evacuation,    125 
et  seq. 
types  of,  103  et  seq. 
Sinuses  and  ankylosis,  169. 
Sinusitis,  948,  950,  954. 
Sling,  apparatus,  379. 

suspension,  principles  of,  367. 
Socket  of  eye,  artificial  dilatation 

of,  996. 
Soft  parts,  disinfection  of,  343. 

large  loss  of  substance  of,  623. 
Soldiers  resistant  to  eye  infection, 

890. 
Sphenoidal  fissure,  790.  o55. 
Splint,   for  wounds  of  knee,  220- 
221. 
interrupted  plaster,  for  fracture 
of  both  bones  of  forearm, 
453. 
laced,  32. 
Splinters,  300. 

extraction  of,  971. 
Stasis,  pupillary,  963. 
Sterilisation    of    wounds,    surgical 

and  mechanical,  35. 
Strabismus,  928. 

Subconjunctival  ecchymosis,  876. 
Sub-deltoid  fracture,  400  et  seq. 
Subluxation  of  the  lens,  885-886. 

of  eye,  885. 
Sub-periosteal  resection,  15. 
Sub-trochanteric   fractures,  494   et 

seq. 
Sucker,  india  rubber,  for  plate  for 

upper  jaw,  661. 
Sugar   treatment   of   wounds,    75, 

et  seq. 
Suicide,  gunshot  wounds  in,  806- 

807,  861. 
Sunlight  therapy,  in  joint  wounds, 

28. 
Sunlight  treatment  of  wounds,  90 
ei  seq. 


Supercilliary  arch,   restoration  of, 

932-933. 
Superior  orbital  margin  and  well. 
fractures    of,    treatment, 
971  et  seq. 
Superposition,   accompanying  lat- 
eral fracture  of  jaw,  612. 
Supporting  apparatus,  32. 
Supracondylar  fracture,  433. 
Supra-malleolar   fractures,    569    et 

seq. 
Supra-orbital  notch,  790. 
Surgery,  conservative,  indications 

for,  275. 
Surgical    treatment    of   lesions    of 

jaw,  734  et  seq. 
"  Suro-metatarsal"   cuff,  of    Oilier, 

259. 
Suspension  apparatus,  380.  427  et 
seq. 
for  fracture  of  forearm,  454. 
for  fracture  of  leg,  561. 
for  fracture  of  thigh,  526-527. 
for  multiple  fractures,  492. 
in  sub-trochanteric  fracture,  500. 
superstructure,  381. 
Symblepharon,  967. 
Syme's  disarticulation,  247,  261. 
Syme's  operation,  illustrated.  265. 
Sympathetic,  section  of  the,  921- 

922. 
Synovial  elements,  destruction  of,. 
21. 
injury,  complications  of,  2. 
membrane,  damage,  of,  2. 
growth  of,  20. 
wounds  of,  treatment  8. 
wounds  of,  types,  9. 

Tampons  of  aseptic  gauze,  28. 
Tarlatan,  use  of,  372. 
Tarsus,  excision  of,  259. 

incisions    used    in    resection    of. 
262. 
Technics,    older    methods    income- 

petent,  34. 
Temporo-mandibular    joints,    mo- 
bility of,  698. 
Tendo   Achillis,   bullet  wound  in, 

234. 
Therapeutic  indications,'primary.m 
shoulder  wounds,  105. 
elbow  wounds,  134. 
wrist  wounds,  171. 
hip  wounds,  187. 
knee  wounds,  206. 
ankle  wounds,  238. 
foot  wounds,  256. 


INDEX 


1035 


Thigh,  amputation  of,  consequent 
on  wounds  of  knee,  204. 

Tibia,  fract  ure  of,  205 ,  574. 

Toes,  malposition  of,  avoidance 
of,  251. 

Tooth,  extraction,  favoring  union 
of  fractured  mandible, 
625. 

Toxic  symptoms  with  joint  in- 
fection, 3. 

Tracheotomy,  to  be  condemned, 
as  means  of  relieving 
dyspnoea, '  630,   664-665. 

Transparent  media  of  eyeball 
lesions  of,  882. 

Transplantation,  941,  944,  950, 
953. 

Traumatic  haemorrhages  into  the 
orbit,  872-879. 

Traumatic  lesions  of  extrinsic  and 
intrinsic  muscles,  879. 

Traumatism  of  the  ocular  muscles, 
879-882. 

Travelling  splints,  161. 

Treatment,  of  fractures,  1  et  seq. 
of     fractured     mandible,     ele- 
mentary principles,   659. 

Trephining,  960,  962,  963,  977. 

Trigeminal  nerve,  lesions  of  the, 
855-856. 

Trochanters,  fracture  through,  186. 

Trophic  troubles,  925-926,  928. 

Trough  splints,  368.  \ 

Ulna,  fractures  of,  484  et  seq. 
Union  of  fragments  important,  in 

fracture  of  mandible,  671. 

Upper  limb,  esquillectomy  of,  343. 

multiple  fractures  of,  490  et  seq. 

Uveal  membrane,  rupture  of  the, 

893. 
Uveal  tract,  affections  of  the,  886- 

887. 

Vaccine  and  serum  treatment  of 
infected  wounds,  95. 

Vallee  and  Ledorinche,  polyvalent 
serum  of,  35. 

Vascular  injury,  289. 

Vertebral  theory  of  cranium,  793- 
794. 

Vertical  fractures  of  mandible,  599. 

Vesical  fistulae,  187. 

Vessels,  lesions  of  the,  870-879. 

Vibratory  shock,  a  case  of  choroi- 
dal injury,  897. 

N^ifious  callus,  treatment  for.  574. 

Villain's  apparatus  for  reduction 
of  displaced  posterior 
fragment  of  jaw,  702, 


Villain's  "crank"  for  use  in 
pseudo  arthrosis  of  jaw, 
716,  717. 

Vincent's  method,  technic,  88. 

Vincent's  powder,  35,  88. 

Visceral  lesions,  187. 

Visual  affections  in  injviries  of  the 
orbit,  laws  governing, 
813-814. 

Visual  defects,  nerve  lesions,  854 
et  seq. 
motor,  854. 
sensory,  856. 
sympathetic,  857. 

Visual     disorders,     after     orbital 
fracture,  1015. 
pathology  of,  849  et  seq. 
relation    of,  to  projectile,    1916. 

Visual  lesions,  according  to  direc- 
tion of  projectile,  813-814. 

Vitreous  body,  haemorrhage  into 
the,  819,  958.  965. 

Vulcanite  plate  appliaftce,  659  et 
seq. 

Vulnerability  of  the  orbit,  897-901. 

Walls  of  the  orbit,  796-797. 
War  fractures,  always  infected,  294. 
War    wounds,    fundamental    prin- 
ciples of  treatment,  10. 
muscle  destruction  in,  296. 
White  atrophy  of  optic  nerve,  782, 
786. 
asepsis,     present    methods    for, 

34  et  seq. 
closure    of,    after    Carrel-Dakin 

method,  52,  53. 
treatment,     modern,     essentials 
of,  35. 
Wounds    and    fractures   of   ankle, 
234  et  seq. 
of  elbow,  129,  et  seq. 
of  foot,  255. 
of  hip,  184,  et  seq. 

operative  technic,  190  et  seq. 
of  knee,  201  et  seq. 
of  the  shoulder,  102  et  seq. 

diagnosis  of,  102. 
of  wrist,  170  et  seq. 
Wright,  Sir  Almroth,  physiological 

method,  35. 
Wrist,    wounds   and    fractures   of, 
170  et  seq. 
evacuation     of    patients     after, 

180  et  seq. 
operative  technic,  rules,  175-177. 
post    operative    treatment,    177 
ct  seq. 


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